HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 7 SOUTH CROSS ROAD 3/17/2026 Commonwealth of MassachusettsTown of North Andover
' 7 City/Town of
Pumping System
S
- = Y Re Re
cord d
Form 4
has
OOPrmation r�nus�tdbe this
substantiall use
the same as providedlh:ere, BPforo{ using fl'�s�6WA"but the
Y �'8 y use ,
y qwith your
local Beard of Health to determine the forrn lhey use. The System Pumping Record must be submit-ted to
the local Beard of f iealth or other approving authority within 14 days fron7 'he purnping date in
accordance with 310 C MR 15.351,
HOUSE: front back sidE rear eIt rlf;h
A. Facility irltormatlofl BUILDING: front back side rear left right
Important:When
f7FCK: under
filling out farms 1. System Location
on the cornpuler, t , ��
use only the lab 7� C t""u) 2"
- -- - -...
key to move your Address
cursor-do not „�--
use the return _._..._ . .- - _ - MA
_..__. _ __-_- _,_ __ __..__
key Chyltown State Zip Code
2 System Owner',
rah
._._... _.._ _--_._.-..
2 me
Address (If different from location)
MA
Cily(T'fhwn Slate Zip Code
Telephone tJurnher
B. Pumping Record
1 Date of Pumping pin �r ". . ..-_ 2 ......... ...._...
I 9 batc Quantity F'umpeci' Gallons
3. Component'. Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
_) Other (describe) ____ _._..__
4. Effluent Tee Filter present? FI Y/umpe'd:
No If yes, was it cleaned? ❑ Yes Cf No
5. Observed condition of component
6. Systemi Porn{:red t3y:
=i��D'3
(save Finetry, Mas 1{R 35E
Name Vrhlt;lr„ License lLrrnb�
Ba1eson Ei- terprisp-s, iric.
Con 1.it) 1.r7y
7 — tlon where contents were disposed'
GL5
Sit e flat of h auler
� Lrate
fgrhalure of Rer,eiviny f=acilily (or etlauh faciqity rr,cclt>t) - mate.
15forni4.doc• 11112 System I'lu-rrping ReCCrd , Page 1 of 4