HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 734 Boxford Street 7/2/2026 Town
of Massachusetts "lown of Nofth Andover
City/Town of
JUL - 6 2026
System Pumping Record
Form 4
Health 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 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 back� e a r le
A. Facility Information ------ BUILDING: front back side rear left right'
Important:When DECK: under
filling out forms 1. System Locatiov-)
on the computer,
use only the tab
key to move your Addr6ss
cursor-do not MA
use the return key. City/Town State Zip Code
0- 2. System Owner:
e
161-:12111
Address(if different from location)
MA
CityrTown State, t A Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Tank 7 Tight Tank ❑ Grease Trap
Fj Other (describe):
4, Effluent Tee Filter present? ❑ Yes 9"t/0 If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of componen��pu ped,
6. System 'lumped By:
Dave Mass IAA95E ass"�l A D 3 1 z
Name Vehicle License Number
B ateso terprises, Inc.
any
7. 'beation why -ontentus were disposed:
GLSD
�Signature of Date
- --
Signature-of Receiving'Facility Date
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