HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 45 HOLLOW TREE LANE 6/23/2025 ..- ... ....
Commonwealth of Massachusetts Town of North Andover
City/Town of
System Pumping Record
_ z
Y JUN 2 3 2025
Form 4
DEP has provided this form for use by local Boards of Health. cHa ths[r[� ftrftntthe
Information rnust be substantially fhi' sine as that provided here. Before usin This form, check with your
local Board of health to determine the form they use. The System Purnping Record must be submitted to
the local Board of Health or other approving authority within 14 days from -h,la-.pumping date in
accordance with 310 CMR 15,351. ---- --- ----- ---- - -
HOUSE: fron back side rear left rig
A. Facility Itnforrl'iation BUILDING: nk back side rear left rig
Important: When
DECK: under
oiling oul forms 1. System Location:
On the oornpular,
use only the labs
key to move your Add e s
cursor do not use the relun r
key. II lfown V A
J r
Zip Code -- - ------
..
<_ System CJwner:
1° -
lalu(f
:—B
Addroas (If different frorn location)
MA
Cfly/Town — -- _-Zfp C- —
State od --- -
'� � 2c ._
Telephone Number
B. Pumping Record
1 m 2
Gate of Pum
ping --Dale ._______.__. Quantity Pumped'.
Gallons
3, Component: Cesspool(s) septic -Tank ❑ -right Tank ❑ Grease Trap
Other (describe):
4, Effluent Tee Filter present? E_) Yes No If yes, was it cleaned? ❑ Yes [] No
5. Observed condition of comp nen( pumper :
6 + 8,
4�
` y s t e rn P u rn t7e d By
Dave, Iiney ..... Mass 1AA95E Mass 1AD317
J,a me Vehicle License Nu nber
Bf .arl F�(erprises Inc
Company
where contents were disposed
r.
3 Dale
51 nature of F eceivin< Facdit
Cor <sttach facility rereip1) (7atc,
(ormA.doC 11I12 System Pumping Record Page 1 0(1