HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 37 CARLTON LANE 7/2/2026 TOM of North Andover
�LN Commonwealth of Massachusetts
City/Town of JUL -6 2026
System Pumping Record Health Department
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.
HOUSE: front a ' ide rear
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
r —
use only the tab 3 7 04C Ale
key to move your Address
cursor-do not r MA
use the return
key. City/Town State Zip Code
2. System Owner:
ratr
--- . 11
0 jkk
Name
Address(if different from location)_
MA
City/Town S#at H Z!*p,Co de>
Telephone Number
B. Pumping Record Z--
1. Date of Pumping Quantity Pumped:
Date Gallons
3. Component: F1 Cesspool(s) 0--Septic Tank F� Tight Tank M Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? M Yes No If yes, was it cleaned? F Yes Fj No
5. Observed condition of component�bmped:
No
6. S tem Pu ped By:
Iil
ave Tinq.�y MasslAA95E Mass 1AD31Z
Name Vehicle License Nu er
Bateson Enterprises, Inc.
Company
Location re contents were disposed:
G LL S D
Signature of Hauler Date
Signature of—Receiving Facility a�a—ch-facility- rece4pt)
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