HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 261 BRIDGES LANE 12/29/2025 Commonwealth of Massachusetts " )f'VO
O Andover
1, City/Tovvn of
= ` 1 stern P u m i n Record
y Y ca N
C)k P has provided this Form 4
form for use by local Boards r f lFealth Orsn � used, but CY r��
inforfnatio'r must Iac, substantially t-ir, ,,ramie as that provided here. Before, u�ir l chec44 with your
Board of Health to deterfnine the form they use 'f'he SystE'm Pur7-tping Record rn s be subrnitted to
the local Boai'd of Health or rather approving rJuihority within 14 dr-lys from the pumping date in
aucorc9anc,e� with 310 C1MR 11, 31,1 _ _._.._. _._ _. _.___._
_ - _.
HOUSE: front ba sidle ea left Pht
...
A. Facility Information - kiftlILDIfvG front, back side rear 77'-t rnf;ht
Important: wnu.n 1
BECK: under
(Ming Grit forms �l. SyStC'ItI I "C,`<iti "r
on Ow"" C;OfTIpuler, ,mpg,
use r]rrly Chrs ta1') .._._. C l� _.....
key fry rnovr;your Ac'Wro
crif
use the
re nt�l L..p_, MFa
use I tr c, r r;t i.r r n ___ ........
y. Cityll'own Strite Zip Cody
2. (':rt em Owner:
�,' - fV rrrrt _ .
6 1 IJ.
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Addross (if different frorn location) �
MA
C;lly(Town st rle, p
- �1
rt;e(:7 i10 C t�l an"1 f7er
g. Pumping Record b` �..
1. Date of Pumping _ 2 C,! .iflntity F urrlpd � -
Gt3lr Ions
6 _7 C .ass6aoc>I(s} }� } ef,7tic f.s nk, (__] Tight tank [.] Grp;ase 1"rap
Corot aonranf:
1 Effluent Tee Filter present? (_..J Ye [ fir: f yes, was it cleaned? L] Yes h] 7
S. Observed condition of corripor ent l urrll:ed
6. Sys te m PIUrnpeei H,y
Dave 1In Mori- 1A�r`t,9SF Mass 1A,U317
_ .. _Y _ __._ _
fVartoe; Vr;nicVr; License Nur'n ,r
E3a �scrn E;=nl�;rE:�rises, Ins:
t orrrpany
7. L`pn e.rr, cc>rlCerlt were disposed:
GL.SD
(aiclrrra(ure of a
.7u�nairrre r f hoer r;lviny f <ac,ilily (or o(ia�ctr (tic.ility rr,r, irrij D)O _
l5form4,doc• ')1112 Syr.t(�rri f'0nYrpir)9 Record PagcE 1 of r