HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 128 MILL ROAD 4/15/2026 Town of NorthAndover
Comrnonwealth of Massachusetts
APR 17 2026
/Town of
Cit y
a System Pumping Record
I
' Form 4 @� artMent
DEED has provided this form for use by local Boards of Health. other forms n-iay be used, but the
information must be substantially the same as that provided here. Before using this form, check wilh yr.,rur
local Board of Health to determine the form (hey,/ use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority widhin 1/1 days from the purnping date in
accordance with 310 CMR 15 351 -
C�t.J S C front t]a c t 5 i cl C r r c f t r p h
A. Facility infOrrllcDtlOf1 BIJILDINCi front, 1�ac e real crft r'
Important;When Df=CK: under'
(Illing out forms 1. system Location:
on iht; compiler, +
use only the
key to move y .our Addrr, \
_.
cursor -do not MR
u e the teturn _--__ - --
Cil riown — -
kc.y. y ale Zipp Code _.
2. Systern Owner:
/Ntv/I �
Addross (if different from location) ---- --- - "-
MA
S -- - --- -
aIe Zip p Code
(� _
Telephone Number
B. Pumping Record
_-
1, Date of Pumping D21e _-- --- 2. Quantity Pumped: Gallons ---------_--
1 Component: ❑ Cesspool(s) ( ic "rank Tight Tank g ( Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? C] `res No f yes, was it cleaned? ( ] Yc's C fvo
5. Observed condition of coi-ripooent f)urnperl
6. S stem P m ed By:
Dave Tlne-. -
___ -- . -_ _---._. Mass s 5 1 l�Ay 5 E Mass 1 A D 311
Name VehlCle License Nu ber--_------------
- - --
-son Enterprises Inc
Company
7. _oc .pn winpre confer is were clispo;>cd:
GLSD
-- - - — - - -
S ig n a l u ro o ff-i a u l e r �•t f e----- -----------.. -----_..---._------------- -------
-
Signature of Receiving'Facility (or a(tach facility receipt) f>a1e
l5forrn4doc• 11f12
Syslc:rn Pumping f7ecorCJ f'aqe 1 of 1