HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 328 FOREST STREET 4/15/2025 Commonwealth olWassachusefts
ivr, of North Andover
C ityffown'of MAY 12,2025
SYStOm, Pumping Record
Form 4
H ea
Department
C EP has provided thitf6rm for use by local Boards of Health. Other forms _
information must be substantially the sane as that be used, but the
k with your
locaI Board of Health to determine the farm they use. The System Pumping Record musthis t be submi to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility information
Important.
Ming out fomns 1. System Location:
on Me use only d�ttab� a (�o c es V ��}
key to move your Address
use the return
key. city/Toroom 0 d __
state
2. System owner.
_Name
zip bode
Te a N1u
a. Pumping Record
1 Date of Pumping 2. Quantity Pumped:
Date+ �
S. Component. ❑ CeSspool(S)
. Tank 0Tight Tank reaSe Trap
❑ Other(describe): Septic
4. Effluent Tee Filter t? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
6- ObS s,con,lat n of, r�per®ent Pumped.,
6. System Pumped By:
Name �
Lnsa NJum ber
t roue �` ice
_.. ,._
;x. Location wn r°e contents re disposed:
Signature of Receiving Fatty(Wallach fafadUty receipt)
t5 .doc•1'iil
System Pumping Record•Page I of i