HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 296 BERRY STREET 6/23/2025 Con-mmoiwveaith of Massachusetts town of North Andover
City/Town of JUN 2 3 225
System Pumping Record
Form 4
ws Health Department
DEP has provided this form for use; by local Boards of Health, Other forms may be used, but the
Information must be substantially the, same as that provided here- Before using this form, check with your
local Board of 1-ieallth to determine the farm they use. The System Purr�iping Record rmust be submitted to
the focal Board of i1e;alth or other approving authority within 14 ('lays from 'he purnping date In
accordance with 310 CMR 15,351 - ________._._.
HOUSE front back side rear left ri
A, Facility information BUILDING: front back side rear left rig
Important:When
DECK: under
(111incd out forms 1 System location
on the cornpuler, /
use only the(ab ,_ rr -
key to move your Address
cursor -do nol )
�/("'_ MA �t t
use the reluln C;fly Tow-n__.._.. ____.__. _
key stale Zip Code
2. System Owner:
Narne
�rer�rn 'r�
....... .........__..- — -....-... _......w..._. ._.._ .. ----- __. .._,........ .__ ._..._. . . ..._... ...----- -- - ..—_- -._.
Address (It ditteroM from loc,alion)
MA
cliyrl own- slate Zip Code
Telephone Number
.___--_.__.__
B, Purnping Record
1. Date of iD a rn p i n g _.._.- ..._____- 2. (quantity Pumped:
C7ate Gallons
3, Component: Cesspools) Septic 'Tank ❑ Tight 'Tank Grease Trap
(..� Other (describe): _ _ _.___.. .........._.___.._
4. Effluent Tee Filter present? [-] YeIS _i No If yes, was it cleaned? [� Yes [] No
5 Observed conditiofi of component I_) �Irnped
6. Systern Pprnpe<d By.
Dave line y Mass 1AA95f Mass 1 i 1Z
.... - _. __...,, .........
Name e Vehicle License Number
Baleson Enterprises, Inc,
ompany
y. � ,a ion where; contents were disF�osed
COLS
signature Of tis3ule( Data
�I nature of tkcceivin f acilit or attach taciiiry re c
w 9 9 Y ( .:ci('rl) Dale
1510r014 doc' 11112 Sysle rya Pumping Record Page 1 of 1