HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 61 FOREST STREET 8/22/2025 Town of North Andover
Commonwealth of Massach(.isetts
AUG 2 5 2025
City/Town of
System Pumping Record
Form 4 Health Department
DEP has provided this form for use by local Boards of I iealth. Other for r-ns may be used, but H)e
information r-nust be substanlially the same as lhnt provider;i hero. Before, using this form, check will) 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 the pumping date in
accordance with 310 CMR 15.351.
HOUSE: ff-ontQ]ID side rear f righT
A. Facility Information BUILDINGi front back side rear left right
Irnportant: Whon DECK: under
(Illing out forms 1. System Location,
on the computer,
use only the let)
key to move your Addre s
cursor do not / MA
use the return —f
key. Ci y(Town
t-- 2. System Owner
Naifne
leltrp �d ,
Address (If different from location) - —
MA
ly own `3IMP lip Code
Telephone Number
---------- .. -
Pumping Record
1. hate of Pumping / � -
P 9 [7at-- _ __-___-- ?. Quantity Pumped: ----_—___..
Gallons
3. Component: ❑ Cesspool(s) _ Sep(ic Tank ❑ Night Tank ❑ Grease Trap
❑ Other (describe): — _�_..__.__
4. Effluent Tee Filter present? �j Yes [_] I\)o It yes, was it cleaned? [ Yes ❑ No
5. Observed condition of component pumped: (/
"0 r
6. System P4trnped By:
@7 e Tlney— --_- -` M s 1Af 955 Mass IAD31Z
Name „[?'T r,,rnher
BafeSon Enferpris , Inc.
Cornpany
/• Location where contents Wefe dlSposed:
GL50
Sig)alure of uler Date
Signature of ReceIv-1 acuity (or attach facility re,.ceipl) Dale
Nonel.doc- 11112 Syalem Purr)ping Record Pape 1 of 1