HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 249 CARLTON LANE 5/1/2025 Commonwealth of Massaohuselts
Torn of North Andover
G = City/Town of
System Pumping m i n Record MAY 2025
Y � g eca d
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Form 4
= � Hoolth De�j
DEP has provided this form for use by local Boards of Health, Other forms r>�i"a f Mut the
inforrnation rnust be stjbstantially the sarne as that provided here. Before, using this farm, check with your
local Board of I-dealth to determine the form They use The System PuITlping Record must be submitted to
the local Board of Ileaith or other approving authority within 14 days from -,he purnping date in
accordance with 310 CMR 15,351. .......__ HOUSE front back side rear left rig
A, Facility informatlot-f EUILDING�. front back side r left 1pt
Important;Whejn
DECK: under
fitling oul loans 1. Stern L oC at101
on the cornpulef,
use only the tabjA
Key to move your --. _._.. _ess
cursor -do not Y , ' J„/ fVIA ,
use Ifte relufrr
CII (raven_,_ __ _. _. _. .
key State IIp ode
1 Sy ten-i Owner
LI-1
Address (If different from locallon)
M A,
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G1ly(Town Sla—
te p Zip Code
q
Telephone Nurnber
B. Pumping Record
1. Date of f�urr7ping - - -- 2, Quantity Pumped
ate Gallons
'3' component. _._] cesspool(s) Septic.Tank Tight Tank ❑ Grease Trap
Lj Other (describe)
4. Effluent Tee Filter present? (-„-) Yes If yes, was of cleaned? ❑ Yes C.3 No
Observed c;or7dltiorl of ornponenl pumped
6. Sysfern lDurn vied E y
D a V e I i_nr .. M_asi IAA-95E - -M-a-ss 1AD31Z..._ -- __.--..
Name .
Vehicle License Number
Raleson Fnlerprlses, Inc.
Corrirsany
1 t..ocalion where Contents were disposed
GLSD
Signature: of Hauler
Slgn,rlura'o of Rer.,+>iv ng Facility (or atl;3ch (acilily rC.cr.;ir>l) rJatc
f51orm4.doc 11112 System Pufnpirrg Record Page i of 1