HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 120 HAY MEADOW ROAD 6/16/2025 ` \ Commonwealth of Massachusetts Town of North Andover
,1 City/Town of
; —_..----s= Systern Pumping Record JUN 16 2025
7
Form 4
Health D
DEP has provided this form for use by local Boards of Hcalth. Other forms may be r9,P,l b'u'1't1�e n t
information rnust be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the (orrn they use. The Systern Pumping Record must be.submitted to
the local Board of Health or other approving authority within 14 days front the purnping date in
accordance with 310 CMR 15.351. _----__-----_..__._._......__.___.----.-----------___--------_._.....__.____
_ HOUSE: front EDside rear left)right
A. Facility information ---- ---- ------ BUILDING: front back side rear left right
Important:When DECK: under
ruling out forms 1. Systern Location,
on the cornpulet,
use only the tab
key to move your Address
cursor-do not Q MA
use the return '
key. Y Town 71aie Zip Code
f( —� 2. Systern Owner
__ r -------- ------ ---------- -- --- -----------
--------s�<� Name
Address (If different from localion)
MA
_ —__ __.._—_----.__--. ______ _� --_____-- _--_
Clty/Town Slalo �ry lip Code —z.-
8-1
-------_---.__
Telephone Number
B. Pumping Record
1. Date of Pumping �`°— ---...------ ?.. Quantity Pumped
Oale Gallons
3. Component: ❑ Cesspooi(s) [ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): --------(---- -----------
4. Effluent Tee Filter present? n Yes No If yes, was it cleaned? ❑ Yes No
5, Observed condition of component purnped:
6. System Pumped By,
_-._.__ __.___— ____._____--_._ Mass 'iAA95E Mass 1AD31Z
Name 1aT)Cle t_icense th.lur er
gnfeson Enter rigs, Inc.
Company
7. Lo ion where contents were disposed:
GLSU
_. -�-___---------_____---------__.-------- � Ire. �
S ig n a 1 ure of N a u l e r Dale
Slgnalure qI Recelving Facility (or attach facility rt;ceipl) Da(e-----------------------�-----"-----""-
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