HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 15 NORTH CROSS ROAD 9/3/2026 i uwn of North Andover
Commonwealth of Massachusetts
—, S P 14 2026
City/Town of
System Pumping Record I opa
,4 Form 4
rtment
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 pumping date in
accordance with 310 CMR 15.351. - --------------..----._—._---_-_-__.
H 0 US E: front back(�SPccclee� rear
earC�ef)iglll
A. Facility Information BUILDING: front back lent right
Important;When
DECK: under
filling out forms
on the ache tab System LOCatlCrl:S yS
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key to move your Address
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usethe return ---- _ —.--__---- --_ _r 4 _..---._...__ _— _--__ -- ---._.—_____----
key.
City/Town State Zip Code
-- 2, System Owner:
Name
learn
Address (if different from location)
_ MA_
City/Town -- --- State — Zip Code --- ---
-__�`� ------- — -- - —---------
Telephone Number
E�. P t�t m p i n g Record --�---- — ___ _
1. Date of Pumping — — 2. Quantity Pumped: -- ---
Date 4G.11ons
3, Component: ❑ Cesspool(s) ;2-'Septic Tank ❑ Tight Tank ❑ Grease l-rap
❑ Other (describe): -------- --: — --------___._�.__
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of componennped:
41
6. System Pumped By:
Dave Tines— _ _—_ Mass 1AA95 Mass 1AD31Z _
Name Vehicle L.irense umber
Bate -nterprises, Inc.
Company
7. Location wlh contents- re disposed:
GLSD '
Signature of Hauler --- ----------- -pate -----__------ ____.--
--- of- -- _ . . -- _ _.._.
Signatur--e of Receivi--n_gg,ha--ciiity_—_far attach f'fality receipt) Date
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