HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 458 FOSTER STREET 3/13/2026 Commonwealth of Massachusetts Town f"NOrth Andover
City/Town of
R 3 0 2
System Pumping Record
F o r t-r1 4
Healthl
DEP has provided this farm for use by local Boards of Health. Other forms may bo use' , C
information must be substantially the same as that provided hers:, Before using this farm, check with your
focal 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 pumping date in
accordance with 310 CMR 15.351 _ HC7tJ�E: _J ro backsirie.._.._r5ar...-lef rif;htY m�
A. Facility information BUILDING: fr-ant back side rear Ief- rip,ht
important: When
DECK: under
Holing out forms 1 System y te Location:
use only the Cab
key to move your Addross,
crusar-do not
C ._._.
_--
M
Lisp the return ._
Key.
cilyC'Cnwn scan. Rip Code
2 System n e r:
=n� Name _..
r _._.r_�. _tion—_.).__.__._......_.._.._ ... ._,...... __ ...,__.,_ ...._.__.__..__.._. .__ ___....._.... . ....._......_. .._-....___. .__....._,._.,___._...... .. ._.........._
Addross (If different from loca
MA
CityCT,pwn slate _ Lip Code
Telephone Nurnber
_.__..___._._-__..--------
..
B. Pumping Record
1, Date of Pumping . i��_____ 2. Quantity Pumped
C)�Ir Gallons
3. Component: [ Cessprooi(s) tic Tank [ Tight Tank ❑ Grease -1"rap
Other (describe):
4. Effluent Tee Filter present? �, ] Yes If yes, was it cieraned7 ❑ Yes ❑ No
5. Observed condition of component pump�d:
'P
6. Sys n�t Pt
a" 7ped F"�y
a' ve„`C Ins r _ ___._.. Mass '1 AA9..7E Mas ' CD31 G
\/e>hlr.lr' 1_ice,n,,e Number
B teso �-nterprlscs_ Inc
....._ _-..
7. [_ Cianwhr Its were dispcised.
Signature of Hauler Date
Signalurez of fkecreiwlny facility(or altart7 taCility resC�ir)t) CJe+t<; � �"
t5forrn4.doc• 11112 Syr,tern Pumping Record Pagc 1 or 1