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Home My WebLink AboutSeptic Tank - Septic Pumping Slip - 130 MARIAN DRIVE 5/5/2025 Commonwealth of Massachusetts o�I.r North Andover r City/Town of MAY 9 2025 System Pumping Record Farm 4 �P has provided this form use local of Nei�lltt��. Other forms rnrry C) �, u fse( O, u Information must be substantially th same as Ihnt p(ovided here. l3efore using Ihus forrrl, check wish yow local Board of Heallth to detern*)e the forrrl lhr;ey t.ise. Tne Systern Purnping Record mt.lst be submitteal to the local Board of Health or othef aq.)prOving Guth o(ity within 14 days from the pumping (,late in accordance with 310 tCMR 15,351 HOUSE front ack side rear Ieft A. Facility Information BOILDIN(a� front back side rear left rif,ht Important; Wl)e)n D F C;K: ur1dP. filling out forms 1, Systern Location: on the computer, � �� ^� Buse only they lab ,,�, - _ - -key to move your Address cursor-do not -.- n MA th use e return kery, City/f'ow Slalr1 Zip Code ' 2 Systern Owner: r-� /� .. _ _ Name rnun �: `V Address(if different frorn location) MA City/Town SIaEe, Zip code Telephone Number - ...._ B. Pumping Record I 1. Date of Purnping _1_. .----- _, 2 Quantity Pumped P Dale Gailans 3. Component: ( Cesspool(s) Sep(ic `tank [� Tight Tank(/ g Trap(� Grease F] Other (describe) __ __..__._. 4, Effluent Tee Filter present? } Yr-w< Nc, If yes, was it cleaned? ( Yes [,) No S. Observed condition of component pumped, or(-,. 6. Systern Pi,irnped By, Dave TIneY _ Mass 1AA.95E I as�"�" 531Z lar7�© V hlr,Ie License Nunn r a eMeson En ELrrises, Inc Company 7. Location where contents were di5pos€d. LS 57b ignaiure a NauVer (Jale Signature of Receiving f acility (or a(lach facility receip!) pale _._.... l5form4.doc- 11112 Systern Purnping Hecord p,q, t o1 1