HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 62 STONECLEAVE ROAD 11/6/2025 p
wn�f�. COMM [� wealth of Massachusetts ��NorthAndover
City/Town of _
` System Pumping (Record NOV 14 202
c Form 4
Health
C: EP has provided (his form for use,, by local Boards of Health, Other farms may b us> twent
inforn-ration must be substantially the same as provided here. Before using ktris form, check w0h your
local Board of f-ieal[th to deterrnirle 1he forn-I they use. The Systern P(_arnping Record must be sul`)mitted (o
the local Board of Health or other appmving aulhoiity wi(hin 14 days from 'he purnping date in
accordance with 310 C,MR 15,351 ___.
lac side rear f rig >t
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A. Facility Inforf`ncatiotl £ UILC.11NG: front l-.)ack side rear lef`t right
Irrt{>rartartt;°dWhan
(v>ECK: under
ffilfng out lawns 1 Systefr) L.ocat'Gil
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0o lire; cornpu(ef,
use only Iho (ab °-' i! 0
kryy r r rnove your ACJd( s / ��
u fe nor 6 �J� /A
sy urc rc;lurn -- ------- �f __.__.__.-___.
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Aodrr-ass (If oiffc rant (fom lo(,alion)
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C)I(y/fown _ Ialb ----------
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Telephone Nurnber
B, Pumping Record
1. Date of Purnping ----- _._...---- 2. QuantityPu >ed
Cia(c rl ( Gallons
3 Corn)o )ent (; ess ool s eplic Tank -
C.._-.� C - (� ) �� p [�] Ti�tri �Tarrk ( ] C;rease crap
0 her (describe) _ _.-. . ........_.......
4. Effluent i e e Filter f.,rese,5nl? L) Yes V0 If yes we)s it r;lo c,ci ' ❑ Yes (� vo
5 Observed condi(ion of (_cvr(> -_nl mped
G Sy tern Pumped By
D-ve line Mass AAOSE Mass 1AD31Z
tJa rat>, Vr huC;Ye; t..IGe3nsa rVurnb.r
B2 eson (_ne erprises In(:
cCrrnpany
7 l_oc afion wl err; C ontents wu,are disposed
V_
_- -
Slyn[?ylurq 0( Fiautt�r Date
;ii nmwe of Recn Ivin< f acflil or a((ach [acdhty receipt) Crate
cHrrr4 C1oC 111k2 Sys(ern Pumping record P,<ge 'I crf 1