HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 312 FOSTER STREET 4/22/2025 ��, Con-)i��or�wealth of Massachusetts
Tarn Of North Andover
City/Town of
System Pumping Record APR 28 2025
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Form 4
t,
Health
DEP has provided this form for use by Vocal Boards of Health. Other form m"cq 0 �I the
information must be substantially the sarne as that provided here. Before using this formc�ieck with your
local Board of Heath to determine the forrn they use. The Systern Purnping Record must be submitted to
the local Board of Health or other approving authority within 14 days from -.herypurnping date in
accordance with 310 CMR 15.351
__ _ HOUSE fro Zback side rea left right
A. Facility information BUILDING; �`r5 back side rear right
Important: when
(7ECK: Lander
(MIng out forms systeIn t_C)cc" Jrl
on the cornpt ief,
use only the Iab �� c .✓ .. _ .__ -- _......__ .....__... ___._.._.__ .. _—. --
key fo move ypur F r �s /p !
cu(sor -do nol ^',d"%....M` (�� �! 4„.�
use the return _.._q__�(..__ ----__.
key (;Ilyfiowr'i Slate Zip Code
2 tern Owner
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slName
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Addro,gs (if differonl (corn locallon)
MA
Clly(1"crwn Slate — _.__ _
Telephone Number
B. Purnping Record
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1, Date of Purnping e_.. __ _..._ 2 Quantity Pumped:
Dale Gallons
3. Component: [J Cesspool(s) Septic Wank ❑ 'Tight Tank g ❑ Grease Trap
Other (describe):
4. Effluent Tee Filter present? (_-� Yes -_ No If yes, was it cleaned? ❑ Yes 0 No
5� Observed condition of Component pt. nped,
6 Systen-t Pumped By.
Dave Tiney _ Mass 1AMSE4 Mass 1AD31Z-
Name Vehicle License Nurnbdr
E3,4kP_son E raker rls s, i(;.
ompany
7 Location where contents were dispow,e;d
GLSD
Signall.ue of t1' "r fo 11 al .
I of Receiving f acuity (or eCfach facilidy rocs ipl) OalFr
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