HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 337 PLEASANT STREET 3/25/2025 Commonwealth of Massachusetts Town of North Andover
City/To'wn of
S 2 ystem Pumping Record APR - 2025
ry Form 4
DpWUWDEP has provided this form for u Hoafthse by local Boards of Health, Other forms rnay bq
information must be substantially the same as that provided here. Before USing this form, check with your
local Board of Health to determine the form they use, The System Pumping Record must be submitted 10
the local Board of Health or other approving authority within 14 days from the Pumping date in
accordance with 310 CMR 15.351,
------- HOUSE: front back d e rear6ii rip,ht
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, CC
use only the tab 1�t"I
..........
key to move your Address
cursor-do not �)-, A,-\�0 t�O- MA
-
use the return -�Ityn-own'------ -S-i2te—"-----'-----'- 7ip Code
key,
2, System Owner:
V/16D
T)
—---------------
Address (If different from Ipcationj
MA-
CityrTown State
tate Zip Cade
Telephone Number
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped,
�5ato Gallons
3, Component: Cesspool(s) Septic Tank Tight Tank ❑ Grease Trap
[] Other (describe)i
4. Effluent Tee Filter present? D Yes fro If yes, was it cleaned? 0 Yes No
5. Observed condition of component pumped:
V)-nf M j I ---------------- ------------- ----------
6, System Pumped By.
Dave TIney Mass I AA95E (-1V-ass 1AD31Z
Name Vehicle License
eateson Enterprises, Inc.
Company
7, Location where contents were disposQd:
-§T-grlaiure of Hauler Date
Signature of attach facility receipt) Date
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