HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 71 WILLOW RIDGE ROAD 7/2/2026 Commonwealth of Massachusetts Town of No�h Andover
City/Town of
System Pumping Record JUL -6 2026
Form 4
DEP has provided this form for use by local Boards of Health. Other forms 4&)MkOft'
information must be substantially the same as that provided here. Before using this form, Ili 1�jur
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 CIVIR 16.351.
HOUSE: ack side red t
frog �Ieft?) right
A. Facility Information BUILDING: r,,o,n back side rear eft right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 1
key to move your Address
cursor-do not MA
use the return CityfTown State Zip Code
key.
2. System Owner:
Name
Address(if different from location)
MA
Cityfrown e
Telephone Number
B. Pumping Record
1. Date of Pumping Date 7- 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) 'zeptic Tank M Tight Tank M Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Z"No If yes, was it cleaned? Ej Yes 0 No
5. Observed condition of compone t pumped:
(6. System Pq ped By:
Mass 1 AA96E ass 1 AD31 Z
Name Vehicle License Numbe
Bateson Enterprises, Inc.
Company
Location wher contents w re osed:
GLSD
atu:7Date
re of Hauler
Signature of Receiving'Facility(or attach facility receipt) Date
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