HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 211 BOXFORD STREET 5/15/2025 Commonwealth Town of
alth of M�ssachuse�ts North Andover
City/Town of
MAY 3 0 2025
System Pumping Record
r Form 4Hea
lt
giant
DEP has provided this form for use by local i3ourds of Health. Other forrrlS may be used, but if)(,
information must be substantially the same ris that pfovided herd, BeforF using This form, c1hock will) 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 pumping date in
accordance with 310 CMR 15.351. -- -
_�_. HOUSE: fron back s' e rear left rif;h
A. Facility Information BUILDING: front back ,ide rear left npht
Important:When DECK under
(tiling out forms 1, System ation'.
on the cornputer,
use only tho tab
key to move your Ad r ss
- - - -
cursor-do not _,,(�
use the return ---Ar?C�`V`'tf"` . MA
key, City/1'own Stale 7_ip Code
2. Syst Owner:
-- 5?rFLn Name
rrr��
Address(If different from localion)
MA
CltyCrown Slate Zip Code
Teleph>��rN�k> �
—-
B. Pumping Record ,r^-
1. Date of Pumping ---- 2. Quantity Pumped,
Dale
3, Component: ❑ Cesspool(s) Septic Tank ❑ Tank'Fight
g ❑ Grease Trap
❑ Other (describe): -._ - .-. -- _. -- ----- --------- _.- -
4. Effluent 7 ee filter present? D Yes Nc') If yes, was it cleaned? ( � Yes No
5. Observed condition of component pumped:
G. System Pumped By:
Uave TIC—_� Mass 7AAg5E Mass 1AD31
Name Vehicle License N r-nber
Bafeson Enferpris�s Inc.
Company
7, n where contents were disposed:
( LSD
Signalure of Hauler tale
Slcdnslure of Recelving Facility(or attach facility receipt) Date
I5for'rn4.doc, 11112 System rlomptng kecord f.7aae '1 rat ,i