HomeMy WebLinkAbout- - Septic Pumping Slip - 35 TIFFANY LANE 8/24/2026 Commonwealth of Massachusetts TOWn of North Andover
City/Town of SEP 14 2026
System Pumping Record
Form 4
Health DepartTent
DEP has provided this form for use by local Boards of Health. Other forms may be used, but t e
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.
HOUSE:5 E: 7fron`t' ack sidme rear left Gight
'
A. Facility Information BUILDING: f�orit back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
,
use only the tab CS e�) '/ —
key to move your Address (
cursor-do not MA
use the return -Aitv[Own State Zip Code
key.
flu 2. System owner:
Address(if different from location)
MA
City[Town State Zip Code
2- 4;
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3, Component: Cesspool(s) Septic Tank 7 Tight Tank 7 Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑� 0 If yes, was it cleaned? F Yes ❑ No 1
5. Observed condition of component pumped:
6, System Pumped By:
_pave Tin Mass 1AA94 Mass I AD31Z
Name —,(LVellcle Lice umber
Bateson Enterprises, Inc.
-60—MPa-ny`--------
7. L Lion where contents were disposes;
L I G L§S
Ig ur Hauler Date
-Signature of ------ pate
t5form4.doc- 11/12 System Pumping Record -Page 1 of 1
o