HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 33 SULLIVAN STREET 5/5/2025 . ... Taa of North Andover
.t� Commonwealth of Massach[,isetts
- et r City/Town of
m __
MAY 2025
System Pumping Record
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Form 4 P`tCrltl
CEP has provided this fofn—r for use by local Boards of Health). Other for r-ns may be used, bd.af the
information must be substantially the samo ras that provided hare. 90ore using this form, chuck with y,:u(
local Board off health to determine the forrn They use. The, system Pumping Record assist be submitle'd 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: rout ack side rea left
. ront rip
A. Facility information BUILDINGback side rear lefl rlfjht
important: When DECK. under
filling out forms 1. Systern Location.
on line corriputor,
use only fhe tat)
key to move your Address(�,
cursor-r not use t h e return
urn --�. ---_
key. City(1.-'._---C - --
own Stets Zip Code
1 2. Systern Owner
�rFr Name
-- -__
Address (If different frorn location)
MA
Clty/Town State Zip Code
Telephone Numt-_-
B. Pumping Record
1. Date of Pumping Cate ? Quantity Pumped.
Gallons
1 Component: [] Cesspool(s) [ Septic Tank [ ] Tight Tank ❑ Grease Trap
C Other (describe): ____ _..... ___ ._____._.
4. Effluent Tee Filter present? CJ Yes (. � No If yes, was it cleaned? (._.) 'Yes No
5. Observed condition of component pun,iped
6. System Pumped By:
GaveTlney Mays 1AA95E ass 1AD31L
Name Vehicle License Nuns er
-@meson [nierprises, lne
_-_._.. _._._ -__ ---------
Company
7, alion where contents were disposed:
Gf.-..D
Signal , hauler Dale
__ _.._-.._—._ _-
SBgnalure of Receiving F'acilrty (or attacY�facility receipt) Date
l5for'mAl.doc- 11112 Systern Purnping Record • 'aka,,, 1 GI 1