HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 71 WINTERGREEN DRIVE 5/28/2026 ell
Commonwealth of Massachusetts Town of North Andover
, City/Town of
System Pumping Record MAY 29 2026
Form 4
DEP hi.,is provided this form for use by local Boards of E lealkh. Other for MPID pt
nformation must be substantially the same. as that provided here. €3afore uslncd this forty,, chact<With your
local Board of Health to determines the form they use;, The Systern Purnping Record must be submitted to
the local Board of Health or other, approving authority within 14 days from -.he purnping date in
accordance with 310 C MR 15 351 ___.. -00 -1�
_ I _NOUSE back side rear f r E,t
A. Facility Information BUILDING: front back side rear le,f�..rifTht
important: Mien (:7ECK: I_Inder
filling out€orrris 1 System Location
on the <;rirrrpuler, p, �
use only the tab
_ ---
key to move your fkddreys
cursor -do no(
USG Ir-r e, fe.tuln ("t M�
_..
key ,iVy own Stale Zip Code
J 2. 5ystern Owne(
Na
I J-1i
Address �f dif'fcrc�r7i born for„ta( �Ica(i) -
_._. _._... MA,
CI(yCPowrt _ .
e
` 7 releplrone t urnt�e
B. Pumping Record
,
1. Date of Plumpinggate _ _.... 2. Quantity Pumped _..._._�._._..._
Gallons
:3. Components: Cesspool(s) pfic Tank C7 Tight Tank ❑ Grease Trap
❑ Other (describe): _.
4. Effluent 'Tee Filter present? [._.] Yes -- t 0 f ye>s, ways it cleaned i� �� Yes [ ) (!o
5. Observed condition of cornpooe.nt purnpm
5L,8'@leson
Sy' ,ten-) F-1 a rrr p e,d B y
Gave 11ney' Mass IA/195E ass 1AD31T
=. _ -_
Vehicle License Numbe
Enlerprlses Inc —
ornpany
c a t i o r wherf. ,r5"ritt nts were c Sposed.,
G)LS
ynature of Hauler7r t
Slynaiure of Receaiviny f acility (or rr11<rc}c (r.rc.,iU(y rr.cCipl) Gate
t5forrn4.doc• 11112 Systern f'Urnping Recorcf Page 1 of'i