HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 20 NORTH CROSS ROAD 8/28/2026 ` Comrnon�Nealth of MassachusettsTown of N011h Andover
w k� City/Town of
-- ° System Pumping Record P 026
Form 4
Health Deartment
DEP has provided this form for use by local Boards of Health. Other forms nrlay be u p ed, but the
Information must be substantially the sane 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: front back Side ea Ieft right
A. Facility Information BUILDING: front back side rear left right
Important: When
DECK: under
filling out forms 1. Sy Lo" c tlon: -J
on the computer, CrT7
use only the tab
key to move your Address
Cursor-do nol ��q MA
use time return _. __..... _...... .. ....... _. _4f_!._
key. Cityfrown Slate Zip Code
2. System Owner;
14f—1-J
leiiv� f `
Address (If different from location)
MA
Clly/Town State Zip Code
Telephone Numher
B. Pumping Record
1. Date of Pumping oath --------..----------- 2. Quantity Pumped:
Gallons
I Component: Cesspool(s) [ optic Tank ❑ Tight Tank ❑ Crease T-rap
UOther (describe): --.._____.___.,_...---_-_--_.__________ ______.._. _.._.._._----__
4. Effluent Tee Filter present? ❑ Yes YNo If yes, was it cleaned? ❑ Yes Cl No
5. Observed condition of component piucriped
6 System Punipecl By
Dave Mass 1AA95E Mass 1AD31Z
Narne Vehicle License Nu her
E3�te' -. ter}'�rlses, Inc.
Company
7. Location w-e nt 1t were disposed:
GLSD
Si mature of Hauler Date
Signature of Receivfng Facility(or attach facility receipt) C1ate.
t5form4.doc- 11112 Systern Pumping Record - Pane 1 of 1