HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 74 COLONIAL AVENUE 5/22/2025 Commonwealth of MassachusettsTown of NOrth Andover
- " City/Town of MAY 30 2025
System Pumpin _—Record
Form 4 e lth a m�,h
DEr' has provideCl this form (or I-,see by local Roerds of I-dry;-lflh, 0tY7er (�rir1 , rn<;1}� 1,>(� usRd, b ulthe
information rnus,t 1 r substantially lh e Sanne as liicl provided rv,,ro Before using this form, check witf-t yor.i(
local Board of Health to deterrnine the form They use. The Syslem Pumping Record mt.lst be submitted to
Me local Board of Health or other approving aulhoiity within 14 days from the purnpiny dale in
accordance with 310 CMR 15.351. -------.__----_------------
_-
-------.___ HOUSr,. iron back s>ide rear left f�f�,r
A, Facility Information BIJ11_(DIN(7) front back t
Important:Whon DECK under
ninny out forms 'I. System Location.
on(hp compuler,
use only the lab ��� G�Cq �_
key to move your Address
cursor -do not
use the re urn - ._ . .__-_ _.-- --_ MAC (
'it crown
kekey, C_ y State Zip Code
2. System Own,
Name __.—_--
nran �.
Address(It different from Iocalion)
MA
C(ty/Town SI<rle ('� lip Code=
— ---
elephone Number
B. Pumping' Record
1. Date of P u rn p i n g ---- 2. Quantity P u rn p e d --!f
daleGa llons
3. Component'. F-3 Cesspool(s) Septic 'rank Fight Tank Grease Trap
❑ O f h e r (describe): ---- _.-- -- _ _. - - _._._ --- ------._ .. -- ----
4. Effluent Teo Filter present? (--.J Y12/,,n-F1,ed
hto If yes was it cleaned? El Yes 0 No
5. Observed condition of corponent p :
6. System Primped By:
Dave Lln_ey Mass 1AAg5L, Mass 1AD31 .
name Vehicle License Nu �...�.-�
Ppf@son En(er rises, Inc_---Company
7,7, L Lion where contents were disposcd
LSD
5lgnalure of tl,ruler _ _ Oa1e rA
Signature of Receiving F-aci{ity (or attach facility feceipl) (laic _--___
iblorm4.doc, 11112