HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 18 PENNI LANE 5/9/2025 Commonwealth of Massach(.isetts Town of NOfthAndover
City/Town of MAY 9 2025
Stem P u m y ping Record
Forrn 4
Health
apartment
DEP has provided this form fc)r use by local Boards of Health. C.7th(,,r forms may be used, but O)0
inforrnation must be substantially tho sarne as Ihlat provide(] here. Before; using Ihis form, Check with your
local Board of Health to deterr-Noe the form Ihr:,y use The System Pufnping Record rnus( ba sut')mitted In
the local Board of f-{ealtf-t or other approving authority wi(nin 14 days frorn the pur-npincg date in
accordance with 310 C MR 15,351
HOUSE front sack stria rear lef f it
A. Facility Information RJILDINC.i front back slrle rear left fq,,,w
Important: Wien DECK. under
(Illing out forms 1. Sy tern Lo a o
use. only tho lack
oo Ifir cornpuler
y _..__,-, .. ...
key o mown yoi.rr Ar jg ,/ /y
cursor-do na1 (j/,Jf /-f'J„(, M�
use the r e t i.r r n _---__—.__ _ _-__---___._..__.._ __-.______._._ _�__..__._ _�.
key, cilyrrown ,Stale Zip Code
2. Systpz Own 'r:
Irrun
Address(If different frorn local on>
M A
Clty(lown SIaIe
Zip(ode
Telephone urnber
B. Pumping Record
'I. Date of Purnping [:) ���-� __ 2. Quantity Pumped. -- � ....._..._._._..
(_gallons
3. Component; ❑ cesspooi(s) Septic Tank ( '1 Tank'Fight
g ❑ Grease Trap
[_) Other (doscribf ):
4. Effluent Tee: Filter present? [__) Yes .J No If yes, wras it cleaned? ( � Yes �_� t,Jo
i. Observed condition of cornponer-it urnfact3:
6. System Pumped By:
Dave Tlney Mass IAA95 Mass IAD31
Namr3 Vehicle t-icense Jurnher
2akescan Fnf rises, Inc --
Company
7, Location where contents were disposrd:
u
Sick alure of H ler
Slgrtaturs of Receiving f acilltV (<>r at(ach facility rrrceip(} 0110 _
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