HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 150 SALEM STREET 9/8/2026 Commonwealth of MassachLasett Town of Nofth Andover
s
City/Town of P 14 20
26
r> System Pumping Record
Form 4 Wit c a .
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the F4
information must be substantially the same as that provided here. Before using this form, checK with your
focal Board of Health to determine the form they use. The System Pumping Record Must bp 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: front< "ck side rear ref. ight
A. Facility Information BUILDING: front b-afk side rear 'Iefr rigtnt
Important; When
DECK: under
(filing out.forms 1, Systern Location,
on the computer, A
use only t to e tab
key to rnove your Address
cursor-do riot � .. _ IVAA
useI h e return _._..__._.___._..__ ._..._ ____ ______. _____...___._ ___..___ ___..__._.._------_..__..
ke lily/-('own Slate Zip Code
Y
"Y4 2. System Owner;
---^ Name
iemn � Address (if different from location)
MA
City/Town State Zip Code
e�p one Nu
B. Pumping Record
Date
—._..
1. Date of Pumping _..___._--_---------_.____._._.._._. ?. Quantity Pumped:
3. Component: ❑ Cesspool(s) — Septic Tank Tight Tank g ❑ Crease Trap
❑ Other (describe) __------___.--__..__._._ -----------_-
4. Effluent Tee Filter present? ❑ Yes __ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of componentpumped,-
...
0. System Pumped By:
Dave Tines_ ............._....--_._—_—_ ass 1AA95E Mass 1AD31L
Name V hicle License Nurn ,r
Bat so__._ terprises, Inc.
---------___-----
Company
7. Location where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Gate _._.... ._ _.
l5form4.doc• 11112 Systern Pumping Record •Page, 1 of 1