HomeMy WebLinkAbout- - Septic Pumping Slip - 26 LONG PASTURE ROAD 8/17/2026 _ C o m m o n w lth of M�ss�ci�usetts Town of North Andover
a
G r City/Town of SEP 14 2026
System Pumping Record
Form 4
Health�^:•
ism apartment
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 purnping date in
accordance with 310 C M R 1 5.3 51. �Nc
--_____---_--_.-__-_ ----_..___.__
HOUSE: r k side re I rift r V 61t
A. Facility Information BUILDING. back side rear let riCht�
ImPortant: Whan DECK: under
(Illinon the
tat 1. S Ccrn Location.
yorms y ys .Y Q '
on the only
the t er, �
c '
key o move your A dress
cursor-do not
use the return
cu mown _..._. _.... _MA
key, Y Slate Zip Code
�•rr- 2. SySte QWne
---
_�' Name
Address (if differeni from location)
M A,
C I lyfTown S i ate 7.4..Code
7 e hone Numt7er
B. Pumping Record
1. Date of Pumping Datei" 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) [ ` ptic Tank ❑ Tight Tank g ❑ Grease 1-rap
❑ Other (describe):
4. Effluent Tee Filter present? [] Yes o If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped: /
__
6. System PUn-sped By:
Dave Tiney _ Mass 1AA95E: Mass 1AD31Z
Name Vehlcle License Nurnb
E3ates — 1te(prlses, Inca
C nf.7any
7. Location where coat nts were di 'sed:
GLSD
Signature of Hauler Date
Signature of Receiving"Facility(or attach facility receipt) Cate
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