HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 TURTLE LANE 7/1/2026 sown of North Andover
Commonwealth of Massachusetts JUL - 2026
City/Town of
System Pumping Record
Y � earth Department
W: Form 4
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. back side rear I right,
_ HOUSE: fran ------._ �
A. Facility Information BUILDING: ron't back side rear left right
Important:When DECK: under
filling out forms 1. System Location*
on the computer,
use only the tab
key to move your Address
cursor-do not G , MA
use the return CityCl own State Zip Code
key.
2. System Owner:
Name
Address(if different from location)
MA
City/Town Sta ip CodeM-__._..�—__.._..,.
Telephone Number
B. Pumping Record
1. Date of Pumping Date Gallons----- ---- 2. Quantity Pumped: —
3. Component: ❑ Cesspool(s) ( peptic Tank ❑] Tight Tank ❑ Grease Trap
❑ Other(describe): __---_---
4. Effluent Tee Filter present? ❑ Yes [ PNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped: k
M
6. ystem`Pumped By:
ave Tine , Mass 1AA95E Mass 1AD31Z
_-_ y _
me Vehicle License N tuber
Bateson Enterprises, Inc.
LqG .D
7. atio6
ere
ten uuer zSisposed:
r
Date
Signature of Receiving Facility(or attach facility receipt) Date
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