HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1895 SALEM STREET 8/8/2025 e ; of M
C -n Town 0f North
orn�onwe�it�� Massachusetts-- Andover
1, Ity Own Of
;(
°! System P u m i AUG,, y �i r7� R e c�r C� 12 2025
rr ;' Form 4
Health Dep
DEP fl�ls provided (his f(.)rrr,i for u)se by "or Lai f'otlyds, of f ior:rllh 0fhef forrrr may be'. pfteiit
nforrration i ust t7<3 >uf>stanlially the sarrrr s^�, Llrr�1 provit)erl Before using This form, CYrer.,d< with y<el.0
local Board of Health to determine the (Of'n) lhc,y use. The Syster—n Pumping Record must be sub(r)itten (o
the local Board of 1-fealth or ottrer approving (runtioi ity within '14 clays from the purnping rotate in
accordance with 310 CMR 15.351.
f I O U 5 E f r o n C b 7cDks ci e r ea r l e f`t r i p h
A. Facility Information Bf-)ILDING front bark side fear leh r�gr,t
important:When DECK t_rn(-ier
01111)g out forms 1 Systern Location:
of)lf of) cornpulagr, ..
r�
se only the lab
key to rnove ycr.rr Ad)dr ss
cursor • do not
use the return VIA
__. --tea c� --��----__--_-
___-
key. City(f own _ _-... ._ lair ---- lip Code
1 0141—__—I u
LI
(�
Address (If difieronl from location)
MA
,Male Zip C<xde
T�elaihhonea Nurrtbr.r
9. Pumping Record
1. Date of Pumping ( a �� ��._....___.._._.__. 2 Q u a n(i t y P u rn p e d. _��1L�..C�.----_--_.____.
Gallops
3. Component: ❑ Cnsepcaal(s) Septic -rank [rvj "Tight Tank ❑ Grease Trap
Ej Other (describe): __._._._.._.____ __ — __.__ _----- _._.
4, Effluent Tee Filter presen(? (_. Yes .._.j 1r10 f ye a, vvas it cIe@neck [_� Yes [] No
5. Observed cond tion of corrrpone nl f L"n
B. Systern Purnped By
Dave TlneS` 4� y n �cj�
_._.._._.. _.__.:... - - �= _Mass 1 AC73 17_
_.._.__ _
t7e 1/rs
ar h11C
BaEesonnferrisrs, Inc_
Company
7, Ii�r) wfr�rc �or7CErrts �rrcre disf�ao5r.�d:
---------..-..__
Sig puler Ual --- ----
Slgnalurc of Recreluing E acility (or a(lach facility feceipl) (late; -..---._._-_--
5form4.doC 11112 Systofn Pumping ileCoul pa", I nt r