HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 211 CANDLESTICK ROAD 6/24/2025 Commonwealth of Massachusetts
Town of Noqh Andover
City/Town of JUN 3 0 202
System Pumping Record
- .Form 4
Health Departure
nt
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 Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from *.he pumping date in
accordance with 310 CMR 15,351
HOUSE: -- front b�l� �°�_
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A. Facility Information BUILDING: front bac "side rear left rift
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key Cliy/Town Stele Zip Code
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Address (If diffe(esnl from location)
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Telephone Nurnber
B. Pumping Record
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1. Date of Pumping - -- -- L. Quantity Pumped: Gallons
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3. Componen(: [ ] Cesspools) Septic Tank ❑ Tight Tank ❑ Grease Trap
L_7 Other (describe): ____ - -......
4. Effluent Tee Filter present? F_j Ye F-1 f"�o If yes, was it cleaned? ❑ Yes No
5. Observed condition of component pumped:
re'rn I- ti'm-tperJ By
eon
TinPy ,r Mass 1AA95E Mass 1AD31Z
Vehicle License amber
F nlerl)rlsPs, Inc
Company
7 ,,6c lion where contents were disposed
Signature of hauler f:7ale ---
Signature of Receiving Facility(or attach facility (eceipt) (Date --
5(orm4.dOc 11112 Syslem Pumping Record Page 1 of i