HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1550 SALEM STREET 12/9/2025 Com nionweallh of Massachusetts Town of NWh Andover
City/ I-own 0f
S s t r r-i P u m i n Record �
Y C 15 2025
r _ - Form 4
4. (DEP has provided this forcn for use by local Boards of Health. Pm0t .fa II the
inforrnation rrlust be substantivally the same are that provided here €before usi g hi., eck with you(
c,)crfl Board of Health to determine the forrn They use The System Purnping Record must be submittec! (e
Me logs,! Bo arci of Health or other cif, pioving 2.-mihority wilhfn 14 days frorn 'hk(; pumping date in
accord Fj rice wilt) 310 CMf 15 .35'1 ___ . _ --
----._.-._. HOUSE: �on back side rear
A. Facilitylnformatior� B(Ji .f ING bn
t 1:3ac4< side rear" Ir;tt
0ECK: Jn er
Important: When
I Itag Old forms 1. Systern Lociriti one
On Ille, cornpulf3f,
use only(fro lab
hey ley move your Addrraas p
r.ursor Oo not
use lice return ,.- ..-. e� ."'..-... . ,.-.. _...__._.. ..... _. .._ _..._., ._, ._ _.
key clly/%'nwr'� Stato Zlp code
. System Owner:
r�
unrn
Aactress (If Uitter(anl borr, ,ncration)
M Fr,
e,llyri(, !r eZI P�codc
Telephone ffurrriner
B. Pumping Record
1 Date of Pr_rrnpinrl � _. __._.._. 2. Quantity Pumped
Dale C rllo,rs
C r (s) [ "X' F [ ) right Tank ( ] Grease Trap
,orc7 acrn,�nt: (_.� uess c,<'ai Se ptic 'Tarnk
I_._. C-)l h e r (describe) _.. _......... ..___.._..._ _ ......,_.__ _.._.._
Effluent Tee Filter present? (._ ,7 'Yr;s (' `No If yes, was it cleaned? Yes [] lVo
5 Obs:;eived c"ondi(ion of corrlponen1 puinped
(f yes" 7 i`f r r7 7 cm,c:l By
(jyve, (-Irley Masi; 1/a,AOS) Mass 1AD311
htfarrreY Veh,cir:; Licr;mse Number
B3 6e'nn Enlpfpn es, ln(.,
.. .._...-_
C"urnpany
7- Uorl wf�rr I� cc�nts we�rc <JI>1�usc;d
ignaluro of i lI fife( )13
Signatufo W F-0-'re1v of f a(;Ility(or st(ach (sc,,ltt), Oat(,
5I0(m4.tJOC' 11112 Systern Pumpiry Rrlcard Page 1 c(