HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 197 INGALLS STREET 7/8/2025 Commonwealth m m o n w e Town of North Andover
alth of Massachusetts
City/Town of JUL $ 2025
System Pumirn -- Record
M Form 4
1 Health Department
Df P has provided t ri.> forr'n for !_rse by IoC�al Boards of iCRIM) Other form; may be used, but the
information rnust be substantially the same as that provided here. Before using ih�is form, Clheck with your
local Board of Health to determine the form They use. The System Purnping FZecorci must be submitled (o
the local Board of Health or other approving authority within '14 days from the pumping date in
accordance with 310 C M R 15.351, �_--.—--___--- ----_-.------------_----.._------_.-__. .
BUILDING'. nt Y)'ack side rear left ri hr
t-i O U S E. f r o n t d c k
A. Facility information f>f„
Important:Vvherr f)ECK under
(filing out forrns 1. Systef ) LOCation:
on the compuler,
use only the lab
key(o move yore Address
cursor -do not �f A%d MA C.
use the return [__— --- - ---- ---_ - -- - -------- ----- ---- - -f � _
key, sIale Zip Code - --
2. System Owner.
r-I
I -J
N arrl E,
�c\
Address (if different from location) -- ------ - --
MA
ly/Town sIa1e
-- -- -- - -
p� Lip Code
---------------
/ a
elcpuone Number
�- ---- �_—.--------------.---._.-- -------- ..- -- - - ---- ----- ------------
B, Pumping Record
1. Dale of Pumping ate 2. Quantity Pumped. ----- ----.---
Gallons
3. Component: (❑ Cesspooi(s) Septic Tank ❑ 'Tight Tank ❑ Grease Trap
❑ Other (describe): -- ___.
4, Effluent Tee Filter present? Yes Nlo If yes, was it cleaned? [--] Yes (] tvo
5. Observed condition of component purnped:
g. System Pumped By.
Dave They -- - ass 1 f,A9 Mass 1 AD31 Z
Name Vehicle License Nv ber
Bai�son Fnf�r�ris�s._Inn._
Company
7, Lo nlion where contents wc(e di5f)o3cd,
( LSD
Signalufe of Hauler Ogle
Signature of Receiving Facility (or attach faciiily rereipl) Date -_------------__-----_-----------_----`-------_---
Oorrntl.doc- 11112 syslem Pumping Record Pr,nr t nr 1