HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 76 EVERGREEN DRIVE 5/15/2025 Commonwealth of Massachusetts Town of NofthAndover
City/Mown of
v-
MAY 3 0 2025
System Pumping Record
— ? Form 4
Healthart nt
DEP has provided this form for use by local f3oa(ds of Health. Other forms may be used, but th)e�
information must be substantially the sarne as that firovided here. F ofc,re using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the purnping date in
accordance with 310 CMR 15.351 ___--.__._
__. 1-IOUSC front c side rear left CD
A. Facility Information BUILDING, front hack side rear tell riE;ttt
Important:When DECK: Under
(tiling out forrns 1. System Location.
on the computer,
use only the tab
__ --- __..---
---- — — -------. __. --- —. __ ----key to move your Address
cursor-do not MIA (3 0Y
�y
use l h e return ----- .___-__--.-----_ _____._-_.
ke , Citylrown Slate Zip Code
2. System Owner:
Name
-------------
Andress(If different (corn location)
MA
Cltcrown ------------_-----__.....
Y Slate Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping f�alP --------------_.___.- 2. Quantity Pumped.
Gallons
3, Component: ❑ Cesspool(s) Septic Tank ❑ Tank'Fight
g [] Grease Trap
❑ Other (describe) ----_ -__--_ _._. ------__
4. Effluent Tee Filter present? C-) Yes (1J No If yes, was it cle@r)ed? �_) Yes (] No
5. Observed condition of component pumped,
6. System Pumped By:
Dave Tlney Mass 1AA95E Mes AD31Z
Name Vehicle License Nur r — A
Bafenn Enferprigeg, Inc.
Comp2ny
7, Location where contents were disposed
.O�L
Signature of Hauler [)ale
-- -------.__..----- ---
Slgnalure of Receiving Facility (or attach facility receipt) Date--------------- _ --------____.__--- _—_.--
I5form4.doc, 11112 Sys(efn Pumping Record Boger 1 or�