HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 165 FOREST STREET 4/23/2026 Cornrnonwealtl') of Massachusetts Tbvvn of North Andover
i ;L Dty/Town of
System Pumping Record
Form 4
(, Ira
nfnrrrlatioDEP has frtrrnustcbcl)s�ab�rm for tarthallt.ase b lone a,�l �i7jtr�f�rov de<�ttic;�r)et� Before check y Dy
11uj h
y rn will-) your
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 'WthOCity within '1(I days from the pumping date in
accordance will) 310 CMR '15, 35'I
1fCtJSE. fron ack side rear cft ngh
A. Facility Informationf3t�lt_DING �r-. t-- a c k side feat left right
important:When DECK: tjnder
filling out forrw; 1. System Location:
on floe t rTrnpuler, �— "�
usa only IITn I<+tr
key to move your Acid109.
cut9or -do not M rL
u v e the return .._.._......_ ._.___.__.e.._.-._.. .:_K._,! ... ._.._. ._.___.. _ -.__�..... ._._._..._- _-
key cilyrrown SI aiF Zip lode
2. Syste weer r
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f
IIIIYR ///r
... -_._.. _.............. —_._......_. ._.
----...._.
Address (If difier(;rol from location) ___. _...__..
MA
_ pCode
eleploorTe t�urnber
--------------------
_n___.____________
B. Pumping Record
1. Date of Pumping ' Quantity F'urnped. ,
3 ComponenC C,_] Cesspooi(s) ] e tic Tan4<
�( ( ] Tight Tank [_] Grease Trap
[_) Oiher (describe): ----_____ _- __
4. Effluent Tee F Iter present? (_.� Yes If yes, was it c;ie.ir)ed? 0 Yes, [_-) No
5. Obsen/ed condition of cornf ,on qnf pA n)er;
6. Lej
>c_I By
Mass 1AA9`� - Mass 1AD31Z_ _. -- -
Vehicle - --.. _____rpriscs, Inc.------------ _ ------- -_ --_ _..
Company
7 oc lion wher 'o -.ents vvefe� distposc,t7
C�LSC
-_ - -- -
&Ignaluro of I lino( Dale -- _
_- - - --
S-6nature'of Receiving -aclhfy or aIli�rh farc,ilify rer„etp!)
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