HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 325 BERRY STREET 4/13/2026 Cori-IiTIonwedlth of Massachusetts
M of North Andover
City/Town of
System Pumping Record APR Z 2026
Form 4
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DCP has provided this form for use by local Boards of Health, Other forms may be eumse the
Information must be substantially tare same as that provided here, Before using this form, check with your
local Board of Health to detern7ine the form they use. The Systern Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from she pumping date in
accordance with 310 CMR 15,351
_.-...__ _._ .____--__-- _r a O U S E f r o n ��- s rear e
A. Facility Information 8UIt.DING: front back 566 rear lefl ril
Important;When
DECK: under
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computer,
ifrc co
tilling
mp 1 Sy 9ten LoCdtloil.
use only the Iab
key to move your AddTf ss
cursor-do not
use the return ..__ — --- — MA _ -------- --- --
E key chy/Towr stale Zip Code
2, S em Own
uir1`:
Name
rl--Au
Address (it different from) locallon)
i
MA
C Ily�rowrt slat p
ZI node
j 'relephone Number
B, Pumping Record _ --
1, Date of pur >in9 C .. 2 Quantity Pum ed�e �---I=o
ns
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3. Component: [-] Cesspools) eptic Tank ❑ Tight Tank ❑ Grease Trap
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[� Other (describe): —- --- - -- __..-- -- ---------
4. Effluent Tee Filter resents
- p t__7 YF-' a If yes, was it cleaned ❑ Yes ❑ No
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5 Observed condition of co 7rponenI pumped
6Ce 'T
'N7ed By'
Mass 1AA95ELMassl Vehicle License No
Enterprises, Inc
Company
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7. Location where contents were disposed:
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D
ynaturEa r7th tiler D tf
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{ eluru of �rciiily (or al(ar,h ftir,ili(y rer,ciiri) Date
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