HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 83 SHERWOOD DRIVE 6/16/2025 Commonwealth of Massachusetts Of North Andover
City/'l own of JU
'a3 System Pur ping Recorci
7
Form 4 A
OF4th De
DEP has provided (his forn7 for rase by local Boards of 1 {ealtt� 0(her fon7�s may t)e if sd, b,�i iqnt
infon-nation must be substantially Lhe warm,_ ais lhnt provided here. Before using Ihis form, check with yortr
local E3oard of Health to cleterrnine (he form lhey use. T he, System Purnping Record muss be sWbmiCted to
the local Board of Health or other approving aulhority within 1'.1 clays from the purnping date in
accordance with :310 f Mfg 1 5 351
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H 0 U S E front ck side red oft r�f,hT
A, Facility Information — � BUILDING front back side rear leh rig l
Important:whon DECK: under
niur,g out Forms 1. Systern Location
oo the computer,
use only the iaU
I<cy to move your Ad ess
cursor •do ooi MA {�
use the. return -- -- ---..—..—____ - ---- �._—_�------ ! -
key. ,ity/Town Slate lip Code
W/ rye_-
r 2. Sys(ern Owner:
t
Sr
Address(If difiereM from location) --- --��_--
MA
Cily(7own Stale lip Code
•• ��`
Teleph II-- NurrlUer
B. Bumping Record
1, Date of P u rn l n c + —.-_-______._..___.
P ) 2 C u a n(i t y P u rn p e d. --- -------
_._-...______.__._
Gallons
3. Component. ❑ Cess10ol(s) Seplic dank [-f Tight Tank ❑ Grease Trap
Other (describe): ._....
4. Effluent Tee Filter present? [_i Yes _ No If yes, was it cleaned? [] Yes [[ No
5. Observed condition of component p ,Iped:
6. System Pi,amped By,
Dave TIn�-- — ---- _ Mass lAA95E Mass 1AD3� _
r`amo Vehicle ltcenso t`Jurri�i
eg[eson �ntgjfr os, Inc -- --- ---- -- --
Company
7, L (ion where conlcnts were disposcd:
�L5
---
Signalure of Hauler Da1e t --
Signature Of Reoelv—In g Facility (or attach facili(y receipt), Dale -------- -- "---_ -----�-----______—._.___
Jf0 7r74,dOC' t��tl Svslef'n Pt,m —, S.or•n,.t . n__ ,