HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 240 FARNUM STREET 5/5/2025 Commonwealth of Massach(.asetts Town Of North Andover
City/Town of
System Pumping Record MAY 9 2025
Form 4 r�
C)BP has provided this form for use by local Boards of Health, Other forms may be used, ���1N��t
inforIoralrBoare� must
to determine hhe fonrf� I�hr�ly sr>rry7111enSy�tem fYefe7 Before,
u�inr.1 This form, chi>ck with yca�ir
substantially P
urn)inc F.ecord must be submitted tray
the local Board of Health or other approving autlrtority within 14 days from the purnping date in
accordance with 310 CmfR 15,351
__...._. _._. ...__._�_.._ L-f0IJSC front tack side ear. left P,fir
A. Facility Information BOILDINGi front back sir.te real left iifru
Important: Whcm 7)ECK. tJnd ei
filling out forms 1 Systern Location
on PIP corrzpuler, el
use only the lab _ G � '1Gro l^ J
_.
key to move;your Addrr sn ��
cursor-do not IN MF
use the return
trey. fyAl'own Stale Zip l ode
{ 2. Systern owner:
stti�1 ray�
Larne
i�(tPIYp �'
Address(If different from location)
rrown
MA
CIt
Y Slain lip Code
1'elephone Nurt7trr;r
B. ptarnping Record f
1. Date of Pum In 71 L_.x ._-_-__ .....--
p Quantity Pumped __. . .
Gale Gallons
3. Component: ( cesspool(s) ] Septic Tank ❑ Tight Tank [] Grease Trap
C Other (describe):
4. Effluent Tee Filter preserik? yesfJ0 If yr,>s, was it cleaned? Yes No
5. Observed condition of component purnpecd.
G. System Primped By.
Gave TIney Mass 'IAA96 ass-�1
hamr� Vehicle License Nu tier
eafeson Pnf .rprises, Inc, --
Company
7, bcatt)i rl whore contents were disposr.d:
®rw
"ignature of Hauler (tale
Signature of Recelvlrig facility tar attach facility (eceipt) C1ale
l5forrnzl.doc, 11112 c>y,atrlrn f'umf>irrg pecord p,j tr, 1 Cat 1