HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 59 SUNSET ROCK ROAD 8/25/2026 L\ Commonwealth of Massachusetts Town of Nofth Andover
City/Town of
S System Pumping Record SEP 14 2026
Form 4
HROth
DEP has provided this form for use by local Boards of Health. Other forms 18"apalft
information must be substantially the same as that provided here. Before using this form, check Tt%our
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 side rear left(ri'g��
A. Facility Information BUILDING: front(n—ac side rear left r'i`gnt-_)
DECK: under
Important:When
filling out forms 1. System Location: (7
on the computer,
use only the tab
key to move your Address
cursor-do not Al MA
use the return bityi i own State Zip Code
key.
2. Systjm Owner-
Address(if different from location)
MA
CltyfTown State _Zip Code
_Telephone Number
B. Pumping Record
1. Date of Pumping 2 Quantity Pumped,
Date allons
3. Component* [7 Cesspool(s) n,,5eptic Tank 7 Tight Tank 7 Grease Trap
F-1 Other (describe):
4. Effluent Tee Filter present? D Yes If yes, was it cleaned? F Yes ❑ No
5. Observed condition of component pumped:
6. SysteTPi�Tped By:
Dqv/e-Tin__ ...... M ss ,1 95E Mass 1AD31Z
m me hFCIWLicense Numll*r
a
Bat
Enterprises, inc.
Compapy,
7. oca'ion where contents were disposed:
SD
_§_11-9,nature of Hauler Date
-9ii—gnatureof Receiving Facility—(or attach facility receipt)
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