HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 719 JOHNSON STREET 6/16/2025 Commonwealth of Massachi,.asetts Town of North Andover
�_ _ City/Town of
_ System Pumping Record JUN 16 2025
7
4' 4 : Form 4
DPP has provided this form for use by local Boards of Health. OtherHeal1 k Ole Pa0 0 t
information must be substantially the same as Drat provided here. eefore t_rsing this form, check will) your
local Board of Health to determine the forth they use The Systern Purnping Record must be sul)mitted 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: front, back Side rear left CD
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: tJndP..r
tilling out forms 1. Systern Location,
on the compuler, (
use only the lab (-- /
key to move your Address
cursor-do nor
use the return w "�es�✓" ---- -._. --- -- MA
- -- -.-.---------
Cit /Town - �-----_-----.__._-
key, Y Stale Zip Cotle
2. Systern Owner
-�aF^L NarTte
-
Address (If different from loca(ion) — ---- "
MA _
Clty/Town SIale ts, �+.,pp-- Zip Code-- ------
--- -10.`- o-� -_. .-. _ -- -- --- ---
Telephone Nurnber
B. Pumping Record
1. Date of Pumping �1-- _.---- 2 Quantity Pumped. -- --
Gallons
3. Component: ( j Cesspool(s) ( Septic 'Tank [] 'Tight Tank ❑ Grease Trap
❑ Other (describe): -- ---- -- -/_-__-------------------- —------.-___-�.___..__._____..__._..
4, Effluent Tee Filter present? ❑ Yes ) No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component purnped:
6. System Pumped By:
M a s s 1 A A9 5 P M a s s 1 A D 31 Z
Name Vehicle License Number
keson EnfPrprisEs Inca
Company
7. Lo tion where contents were disposed.
LS
Signal Hauler Date --
-- _--------_------ ----
Signature of Receiving Facility (or attach facility receipt) Dale --
Worm4,doc- 11112 Systern Pumping Record • Page 1 oil