HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 39 HAWKINS LANE 8/7/2026 Town of Nosh Andover
Commonwealth of Massachusetts
P 1
CityiTown of
System Pumping Record
Form 4 cap m'i D p ent
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the Sarre 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: back side rear right
A. Facility Information BUILDING: 17P back side rear left right
Important:When DECK: under
filling out forms 1, System I-ocation'
Lin the computer,
use only the tab
key to move your Address
cursor-do not MA
usethe return ___._...__. __.__. ".:-----------_.__ __._____. _.__-_.,. ___ _. _.._.._ � ._----._—_-_._
key.
City/Town State Zip Code
A
11
2. L
tear Owner:
_ _vo— ---- q.a
Name
Address (if different from location)
MA
Cityl7own State / Z' Code
C
Telephone Number
B. PLIMping Record
1. Date of Pumping __.____._.____...__-_. ___—_-_-- 3. Quantity Pumped:
Dale Gallons
3, Component: [] Cesspool(s) e"_5e_ptic Tank ❑ Tight Tank ❑ Grease l-rap
[ ] Other (describe): ---.-._... _---_.__--- _ _.._.._._.._ _-----_----_
4. Effluent Tee Filter present? ❑ Yes a If yes, was it cleaned? ❑ Yes ❑ No
5, Observed condition of component pumped:
6. S tem Pun ped By:
ave Tines-- - Mass 1AA95E Mass 1AD31Z
_w —__--__-.
Name Vehicle license Number
Bateson Enterprises, Inc.
ebmpany,
F
7. Location whe con nts e e disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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