HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 125 COLONIAL AVENUE 5/7/2025 Commonwealth of Massach(.,isetts Tovvn of lVorth Andover
City/Town of MAY
15 2025
System Pumping Record
Form 4 H 'th Departm
this form for �jse by local Bourds of Health. Other f0fl-T"Is may bc,_ used, but (f)e
DEP has provided .
ent
information n-i(.ist be substantially the same n ihni ofovided here. Refore t,)-,ing this f0rt7), Check with ynw
local Board of Health to determine lhe form lhey use. The System Pumping Record must be, sutDmlltecj to
the local Board of Health or other approving authority within 14 days from the bumping date in
accordance with 310 CMR 15.351
HOUSE: fQjn ' back side rear of right
A. Facility Information B U 11.D I N G: front back side rear left ciI,,ht
Important; When DECK: f,,j n d e r
(MIng out forrns 1. System Location:
on the computer,
use only tho tat)
f J
kev to move,yout Address
cursor-do not MA
use the, return
key, Cityff*own Shale Zip Code
2, System Owner:
Nome
Address(If difierenl (rorn location)
MA
Ity own Stale lip Code
------------
.1ephone Number
-------------
B. Pumping Record
/5ZX1
1. Date of Pumping 2 Q�rantit PurnppdEraIe y ___------
Gallons
3, Component: ❑ Cesspool(s) Septic Tank ❑ 'Fight Tank I Grease Trap
❑ 0(her (describe): ------ -------
4. EffiLient Tee Filter present? [--j Yes NC) If yes,, was it cleaned? [--] Yes No
5, Observed condition oi component pur-riped
6, System Pumped By,
-----------
Dave TI Mass 1 AA95 E- ,--MZ_a_ss 1 AD3_fN'
qey
Name Vehicle License Nrnfer
e2leon Enter rises, Inc
C'ornpany
T (ion where contents were disposed:
GLS
---------------- ,_tr_
Signa[u(e of Mirtlet tale
Slgnalura of_Rec_e1_vI,, T_a cIrlty (or anacr) bale
15form4.doc, 11/12 System Pumping Record pag
e 9, 1 ()f I