HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 141 STONECLEAVE ROAD 4/18/2025 Commonwealth of Massachusetts Town of Nofth Andover
APR 2 8 2025
City/Town of
System Pumping Record
Form 4 Department
DEP has provided this form for Use by local Boards of Health. Other forms may be used, bLji the
information must be substantially the same as that provided here. 9(--,,fore using lhis form, check will) yow
iocal 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 2c ', rear left,side (
A. Facility Information BUILDING: front back side rear left right
Important; When DECK: under
filling out forms 1. System Location
"U"
on the compuler,
use only the tab
key to move YOW Address
cursor-do not
use the return --- MA
---
key. Zityr-'own Zip Code
2, System ner:
Name
Address (If different from location)
M A
C[tyrTown slate Zip Code
Telephone Number
B. Pumping Record
X'6f
1, Date of Pumpingaa(e 2, Quantity Pumped: -��a I I o—ns
3. Component: ❑ Cesspool(s) Septic Tank ❑ 'Tight Tank ❑ Grease Trap
0 Other (describe),
4, Effluent Tee Filter present? 0 Yes
-1 No If yes, was it cleaned? EJ Yes 0 No
5, Observed conditioncomponent m f nt P ped:
6, System Pumped By:
Dave TIney Mass 'IAA95E 7'931Z
ass s
Namo Vehicle, License Nur<hfer!
gnfescn lnkclrprigos, Inc.
Company
7, Con where contents were disposed
'ignalufe of Hauler Date
—Signature of R ,qecelvl� 'Fa—cii-lfyFol—atlac-h-fad-iltvy-fecei-receipt) b —-------
Date
WDM14.doc, I'M2 System Pumping Record Parjn 1 or,I