HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 80 BOSTON STREET 7/14/2025 Comrnonwealtr� of Massachusetts Town of North Andover
City/Town o f
` JUL 2 1
' S stern Pum in Record 2025
r
y
Form 4 Health D
apart en
DEP has provided this form for use by local Boards of Heallh. Other forms may be used, bu� the
informaliora must be se.ibslanlially the same ac that provided here Before using this form, check with your
local Board of Health to determine the forrn they use The System Pumping Record rnust be submitted to
the local Board of Health or other approving authority within 14 days frorn -,he purnping date in
accordance, with 310 CMR 15 351 __ � _...._ � __._X.__--
_.. HOUSE front �� f)T r f
side rer i V
A, Facility Inforniatlon BUILDING firont lnacfk� aide rear left rid
Important; WYt(tn
DECK: under
y S(erTl l at
on the cram a.11aar,
use only the I a b
key to rnove,yo,w s5 ��q r
cursor do noI M
use in(,, reWfn ;Ily/r<w_ . - - ___..- l -._ _ ._...._ _
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key Sate Zip Code ._._....
)yStE?rrl Owner
f),�i raeS
w 4 Ar
Address (I( different (rcrrn lac,aliorr)
MA
GIly�rgwn State _ Ll Code
Telephone Number
--------------__. ___...... __-.._-.___—�
B, Pumping Record
1. Date of P u r n p i n g Dale _._.--_-.._------.__.__. 2. Quantity Pumped:
G2Vicrns
Component: ( .] Cesspool(s} [ eptic Tank ❑ -right Tank g ❑ Grease Trap
(� Other (describe) __.-.__
4. E fir Iuen( Tee Filter prese nt �s
f _._ ` ) No if yes, was it cleaned? Yes (� No
5. Obsewed condition If C:Car-riponenl pumped
6,
)yste;n.a C-'l)rnpr d by
Dave; 1"I e-Y _-. _ Mass 1f�A95E Mass 1AD311
Name VrirK,l(. License fVurn, yr
Company
_ot;�ahorawfi fe, contents were disl:rfa.�rw�c'7�.
7
CGS
_.
tilgn tuiE:: of I1rau1er Dale --
_
Sign Xlure of f-�ecf;w liig Facility(or �)U2ac}) (aticili(y rr,rr�ir,l) Gale _- -
5farrn4.Ja „ 11I1E oysiern Pumping f�erortf Page 1 tat 1