HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 144 GRANVILLE LANE 5/16/2025 of North Andover
C\ Commonwealth of Massach(.isetts Town
City/Town of
=1 ° System Purrpin Record
4 Form 4 Health DepartMent
DEP has provided this form for use by local Boards of Health. Other forlris may be used, but the
information must be substantially the same @s Ihal provided her,,,. Before using this form, cheek with your
local Board of Health to determine the (orn') Ih(:ey use the System Pumping Record rolls( be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 C'MR 1 5.351 ---
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___-_. HOUSE front back Jole rear Irf y ht
A. Facility information BUILDING,. front brick side rear left rif,,hl
Important:Whon DF('K [,meter
(Illing out forms 1. System location,
on the computer, / �//
use only the lab ---/-__—__5�..._._n_._0
key to move your Address
cursor e do not MA Q� L
use the return Cit /Town c-e�`✓'��—_ ---_— -- -- _ --'—'_—__--
key. y -- -- - stale — -- -- - 7_ip Code
2. Systejr Own f.
Narne
Address(If different from location)
- — ------ ---
MA
CI(yTTown 51 Wle - Zip-Code
_..__._...__..-
Telephone Number
B, Pumping Record //!/,
1. Date of Pumping � a'2' ---- 2 Quantity P —
Da1e . umped. Gallons
3. Component: ❑ Cesspool(s) ] Septic Tank ❑j Wight Tank ❑ Grease Trap
Other (describe);
4. Effluent Tee filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component p rnped:
6. System Pumped By:
Dave Tine% — -------__—_-- Mass 1 AA 9 5 G AA7 1 Z
Name Vehicle License Nur er
Uew En(erp Lns , Inc.
Company
7. Location where contents vve(e disposed:
lSD
Ignalure of Hauler 0aie
Signature of Recelviny Facility (or aPlactr facliity re,ceipi) Date
l5(orm4,doc• 11/12 Sys(®ern Pumpk,q Recoal p or,. t (it .I