HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 74 STONECLEAVE ROAD 9/1/2026 Commonwealth of Massachusetts Town of North Andover
City/Town of P 14 2026
In Sy
stem Pumping Record
Form 4His
'R°"
M 'jDartment
DEP has provided this form for use by local Boards of Health. Other forrTls may be used, but the
information must be substantially the same as that provided r'lere. Before using this form, check with your
local Board of Health to determine the form they use. The System Purnping Record must be submitted to
the local Board of Health or other approving authority within '14 days fron) the purnping date in
accordance with 310 CMR 15.351,
HOUSE: front ac side rear left �7h
A. Facility Information BUILDING: front back side rear left right
Important:When BECK: uncipr
uon the compuier, 4�
se and the tab
rtt Location'
(Ming out farms I. Syste
key to rnove your Address
cursor. do not MA
use: the return _._., _- ._...... . ...----
hey. Cilyll"own Slate Zip Code
2. Systern Owne .
Name
renrn �' �j
_ Address (If different from location)
MA
Clly/Town State —
ZIP Code
Telephone NumUer
E3. Pumping Record
Pumping t-)
1, Cate of 2. Quantity Pumped.
1 Component: C;esspool(s) (Septic Tank ❑ "Tight Tank g ❑ Grease Trap
❑ Other (describe).
4. Effluent "Tee Filter present? ❑ Yes { No If yes, was it cleaned? (� Yes ❑ No
S. Observed condition of cornpone t pumped;
644
G. System Plumped By.
Dave Tiney Mass 1AA95E Mass '1AD31Z
---_.__-... __...__ _--_--_- __._
I ncr ar vehicle License Nur fiber
Ba on Enterprises, Inc. u M
Company
7. Location where contents r�cfisposed:
GLSD
Slgnalure of Hauler (late
SI ralure of Receiving =aality or alfac h f7cilit�recei l)
Date
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