HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 594 BOXFORD STREET 9/9/2026 Town of Nofth
_ Commonwealth of Massachusetts Andover
f City/Town of .
P 14 2026
System Pumping Record
f 'r Form 4 Heal'th Department
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the Sarre 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 C Nl F� 15,351.
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HOUSE: front truck Cliff fearf1 rigi
A. Facility Information BUILDING: front back side rear Ieft right
Important; When
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filling out form 'I. Systern Location'.
on the computer,
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City/Town State Zip code
2. S stem X ner:
_ r -
Name
rerun �
Address (if different from location)
MA
Cily(Town State Lip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Pumped,- Gal
2. Quantity
3. Cornponent: Cesspool(s) eptic 'Tank ( ] Tight Tank ❑ Grease Trap
❑ Other (describe}:
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component nips
6. System Pumped By:
Dave 1-Iney.____.__._.._... Mass 1AA95E ass 1AD31L
Name; Velilcle License NL ber
Bat n Enterprises, Inc.
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7, Location
where contents were s
GE_SD ic
Signature of Hauler Date
;7Ignature of Receiving Facility(or attach facility receipt) Date
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