HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 18 EQUESTRIAN DRIVE 3/10/2026 Town of North Andover
Commonwealth of Massachusetts
a City/Town of MAR 16 2026
Systemmping Record
Form 4 Healiq
,.,i pax
DEEP has provided this forma for use by local Boards of Health Other forms may be used, but the
information must be substantially the sarne as that provided here. Before using this form, check with yoL.,r
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the purnping date in
accordance with 310 C M R 15.351. ----------------__----------
HOUSE: fro T�5 a c side rear eft r, i h t
A. Facility information BUILDING: front back side rear left ri;r,t
Important: When DECK: under.
filling out forms 1, System 1 oration
on the cornputr;r,
use only the tab
key to move your Address
cursor -do not ) / MA
.r s e the return —!Y =V �C - -- ------- - --- -- — ._.
kc C.it Irown ___.. . ___-_- State Zip Code
Y
� ran
2. System Owner:
Q
�- ame
L--1-4z
�•
Address (if different from location)
MA
-----.___ -.
Citylfown �__-__-_ State Zip Code
--- - �t GCS ___T'olephone Nr,rmber
B. Pumping Record
__-- _
1. Date of Pumping �. a�� �* 2. Quantity Pumped. ----.---_____
Gallons
3, Component: Cesspool(s) Septic Tank ❑ Tank Tight g [� Grease Trap
❑ Other (describe),,
4. Effluent Tee Filter present? ❑ `res ) No If yes, was it cleaned? ElYes No
5. Observed condition of component pumped:
6. System PGimped By:
Dave T I n eY_ Mass 1 AA9 5 E M ass J31
Name Vehicle License Nur ber --_...____...__..
eateson Enterprises, Inc.
Corrrpany
7. 4Signaro
ere contents were disposed:
uler Date --�- --- - _--
_
Signature of Receiving Facility(or attach facility receipt) Date
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