HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 79 LACY STREET 4/22/2026 �L\ Commonwealth of Massachusetts ToWn of No I`i Andover
j City/Town of L&2 !ay�e-r MAY - 6 2026
System Pumping Record
Form 4
Hlc�aiv,)
DEP has*provided this for for use by locai Boards of Health. Cther-ForrMis may De UP42%RD t
information must be substantialiy the sane as that provided here. Before using this forrn: check with your
local Board of Health to determine the form they use. 7 h:e SySter-,, must be submitted to
the local Board of, Heafth or other approving authorftywitulir, 14 days frorn the pumping date in
accordance with 310 OMR 15.351.
A. Facility Information
important When
filling out forms 1- System Location:
an the cornputer,
use Only the tab
key to*rove your Address
cursor-do not
use the return
key, 71p Code
2. Systern Owner-
CIVNOL -n Vr
O!ty�"rcrwn S4
Za-e Zip code
elsph.cne Nurnber
B. Pumping Record
Date of Purl-Ding a�e ty 2. Quantity Pu mps�4J:
Date Gallons
3. Component: 7 CaSS!000i(S) tic Tar kF7 T;ght Tank
71 Grease Trap
7 Other(describe):
4. Effluent Tee Filter prese:,i, Yes
Yes- Was it cieared? 7 yes 7 No
5. Observed corldi'LiOrl Of component pumpc-cj-
_5
A�'
i—Forrm.natto, or Ii of this estimated
n9n. - IIIIQMO ;;�tne b M s oum,�)Ing. Not.reSgOnSibie b and the date-above.
Syste /l ed
A /
Nano
Deveicprnent Corp. d/b/a S' wa--'s Sept Uc
Service
7. Location,whar*9 cont--Inta Were disposed:
GlObai ErwirorrnL-ntai, LLC
20 So. MiII.St, .Bradford, MA^-, s
as
See;-bove
Fad;Ifty
a above
I..
Purng)l,g Record-Page 7 of I