HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 434 BOXFORD STREET 7/22/2025 Commonwealth of Massachusetts Town Of North
Andover
City/Town of
S stir �� .-.__.
r
y um [)ing Record AUG 112025
Form 4
DEP II a x prrwir{r�2rl oils f<urn iCrr l.r,r�� t;ry local 13w,,a( l Cal H alltr CJt r� C���1�� �
p
inforn7otior7 rr ust 1>E, ,ut7 (� nli lly the s i7� �, Yhr �l f rcrviriF�ri linrr� f.'� fc>re using lhIr, forrr7CT�A k will) your
local Board of Health to determine the form lh( y r.js(2 The System Pumping Recorc-1 rTiust tiny subrnit�teci w
the local Board of Health Of other approvincl :authorlly wiillir,, 14 Clays from the, purnping dale in
accordance with 310 CMR 15,351,
_._ .. f-i O U S C^ r C)n C back side e t g h t
A. Facility Information f3UILDHvJ(,� front. hack rear i e f r rlgr)I
Important;Whon C ECK der
Wling OLA forms 1 Systr.3n") L. ocalion'
on the compulo+ro
use only Iha {ab
key[o(nave yctrrr Adrirass
<ur;or do uool
' ".. _.. _._
5� ._._.._...._
use he (el. r MA
key, Tip Code,
--- ). Sysiern CiWr)E>r.
urvn �•`�V
Addcoss (If different f(orn location)
MA
-_ ___----- _.. _ _.__.._ _.__.
Clty(T'owr7 Slam lip Code
c raj�; -----
I clephone Nurnbear
,._..._...._— ._.____...._._—�-_....�.._.__._� .......,._..._. _... ......_.. .-.-_ _._-..._-- ... ....._..----.. _..._...._ ........,__.. .. .........._. .. .._._._.-._�_..._... .........
B Pumping Record
'l. Date of Pumping - / -`"' " _.._..__._...,_._ ' gallons
f� J quantity F urrr��ri. ----2� ..__._... _...
3. Component E.-} Cesr;Pool(a) Septic `Bank (D Tight Te,nk [� Grease Trrp
(_j Other (describe): .... ._.._.-___-...... ------
,1. Effluent Tee Filler presew'7 (_j Yes xiI'lo ye,,S was it c:le��jn d? Yes ('J f,io
5, Observed condition of c,c rr7ponent pumped:
—_________•Gbr -r
5. System Pufnp>ed By:
Dave Tine ga s y,Ac Mass IA031Z
G+lame VleyY�ilcle License H er
asnn nlersaPl�ns lnr
Corrtfp3ny
7, Loc iC)n wi) rc; cvn(cnls wcfe dispo:)ed
GLSC1
- � _
51gnaEure al Hauler Oate ._. ______....
JVC}rlriltJ(e o e,c,e v �trt aaliry or attach �u;ilify rCu;e'iypl} Clar1�
Sfo n4.Uoc 11112 7y,le to Pumping fwc;rord � r'a(fe t of�i