HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 50 LOST POND LANE 7/1/2026 Commonwealth of Massachusetts Town of Nofth Andover
City/Town of JUL -6 2026
System Pumping Record
H e@
Form 4 1th Department
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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.
side right(�
HOUSE: front bac rear 1
<-��,C�e
A. Facility Information BUILDING: front back side rear le •-.dOt
Important:When DECK: under
u
lling out forms 1. System Location:
n themputer.se only the tab - g)
key to move your Address
cursor-do not A.) LAI/- MA
use the return
key. CityfTown State Zip Code
rr-
2. Sy st;T Owner* (
062 4
1
Name
Address'--(if-'-different from location)
MA
--6)Ttrf-ovin- State Zip Code
;fAlepho
(Numb r
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) &73"§-eptic Tank 7 Tight Tank ❑ Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? F Yes ❑ No
5. Observed condition of component pumped:
System Pumped By:
D Mass 195E �ass 1AD31Z
Dave
Name Vehicle License Number
Bate.sonEnterprises, lnc- ------ ------
I _ —
mpany
-
D�
Na Be
7. Location where contents were disposed:
GLSD
rgnature of Hauler Date
-Signature of Receiving-F'�-��Ifi (or attach-'-f'a-c-i-l-it-y-receipt) Date
t5form4.doc- 11112 System Pumping Record-Page 1 of 1