HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 517 JOHNSON STREET 6/16/2025 of
Commonwealth of Massach�isetts TO"' North Andover
City/Town of
JUN 16 2025
System Pumping Record
Form 4
DEP has provided this fOrrT-1 for use by local Boafds of Health. Other forms may be used, bN)e
information must be substantially the sar-ne, as (hat provided here. Before using this form, check will) your
local Board of Health to determine the form lhey use. The System Pumping Record must be submitted 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(Ea side rear left EIP13
A. Facility Information BUILDING� front back side rear left
Important: Whan DECK: undel
tilling OW forms 1. System Location:
on(he cornpuler,
Use Only the tab
key to MOVe Y01,11 Address
cursor -do not MA
use the folum
key, (y own Zip code
2. System Owner
N a M�t
L -/
M
Address (if different from location)
MA
CltyfTown Stale, Zip Code
Telephone 4 Umber
-—----------—------------
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped.
Gallons
3. Component: ❑ cesspool(s) Septic Tank ❑ 'Tight Tank ❑ Grease Trap
0 Other (describe): —-------------
4, Effluent Tee Filter present? 0 Yes V4 No If yes, was it cleaned? [,-] Yes E] No
5. Observed condition of component PLImped,
6, Systern Pumped By:
Dave TLne2 Mass 'IAA95E Vlass 'I AD31Z
Name Vehicle License Nurnlaer
pnEeson Enterprises, Inc
Company
7, Location where contents were disposed:
Signature of Hauler Date
_S_Ignajure'of Receiving (or attach facility feceiril) Dale
Wormit.doc, 11112 System Pumping Record Page 7 of i