HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 10 CAMPBELL ROAD 7/1/2026 T,,^Wn of NON Andover
Commonwealth of Massachusetts
JUL - 6 2026
City/Town of
System Pumping Record
2- n 3w. Form 4 Health 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 CIVIR 16.351
rear lei_________.___
le �right
HOUSE: front bac�14W"'
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System L, Lion:
on the computer,
use only the tab )❑C)
key to move your Address
cursor-do not MA
use the return
key. City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
MA
ZT,tffo�WFI -Siai-e- Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) [,-��e�tic Tank 7 Tight Tank ❑ Grease Trap
❑ Other(describe):
4, Effluent Tee Filter present? ❑ Yes 0 If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumo ed,
z ,
6. System Pumped By:
_gave Tin��y Mass 1AA95E M4 1AD31Z
IN
�,Name Vehicle License Number
B6togoii Enterprises, Inc.
"C any
Location wher contents were dispq5jad-.---'-
GLS
T. 71 "
D
Signature of Hauler Date
of k-eceIv-1n-g'Facifity- r-e-c-e-i-pt)—------Signature ------
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