HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 60 ROCKY BROOK ROAD 6/29/2026 Commonwealth of Massachusetts Town of North Andover
City/Town of
System Pumping Record JUL -6 2026
tiY Form 4
D
DEP has provided this form for use by local Boards of Health. Other forms may beus9p, ffttpaent
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
HOUSE: front C-11c� side rear O�right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System L ition:
on the computer,
use only the tab
key to move your Address
cursor-do not )"v MA
use the return
key. City/Town S#ate Zip Code
2. System OwnT r*
Name
-Address(if different from location)
MA
Cityfrown State Lj'-Zlo code
Tele'--2on
Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Component: Cesspool(s) Septic Tank M Tight Tank M Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? M Yes CJ'No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:n
Dave. System
Mass IAA95E Mass IAD31Z
me Vehicle License N tuber
Bateson Enterprises, Inc.
Company
f"�
7. Location whey dQ�rterjts were disposed:
.qLSD
-Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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