HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 485 FOSTER STREET 2/25/2026 Town of North Andover
L\ Commonwealth of Massachusetts
City/Town ofMAR
vq ° System Pumping Record
= -= Form 4
?" Heal-th Department
DEP has provided this form for use by local ("hoards 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 your
local Board of Health to determine the form they use, The System Purnping Record must be submitted Io
the local Board of Health or other approving authority within 1,14 days from the pumping date in
accordance with 310 CMR 15.351
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A. Facility Information BUILDING: front back side rear, left ripht
Important: When DECK: udder
(Illing out forms 1. System Loc2tl0
on the compuler,
use only the tabs
key to move your Address -
cursor-do not
use the. return — __—_.__.__ = _.. � —._... .. .... ... ........_ 'VIA
kr,,y, Ci— own State Zip Code
ED2. Syste caner•
c� ,r
Name
unvn .ry`Y•
Address (if different frorn location)
MA
City/Town Slate Zip Code
-— m - - --
Telephone Nuber
B. Pumping Record
1. Date of Pumping -._ 2. Quantity Purnped
Dale Lallans
3. Component: ❑ Cesspool(s) ,..-8'e"ptic Tank ❑ Tight Tank [] Grease Trap
Other (describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? (LL_] Yes ❑ No
5. Observed condition of cornpon �nt,�pumped:
f
6. S.ystem Pumpei By:
DaveTlne Mass 1AA95E ass 1AD31Z
Name Vehlclo License Numb r
.._...._ ente �.�r.
r son Enterprises,—Inc,
Com an
7 Location were c tea r' e Cfis�ai sed
Signature of Hauler
Signature of Recelving Facility (or attach facility rc�ce�ipU C>atr —
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