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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 18 PENNI LANE 5/13/2026 Wn of Narthi Andover C 00 Trrionvvealth of Massachusells C'f /�1-o w r� f MAY 2026 Y System Pumping Record xf Form 4 Health Department C DEP has provided this form for use by local (3oards of Health. Other forms may be usQd, but the information rnus( be substanlially flee sarne as th,il provided here. Before using (his forrn, check with local Board of HealIh to dr,,(crfnine ffie, foml Ihey use. The Systern Purnping Record rnust be submitte the local Board of Health or other approving authority within 14 days from '.he purnping dale in accordance will) 31 U G M R 15,',51 - --------. _._ -- ------- -- HOUSE: fron - ar t� �irl A Facility Infort-nation BUILDING front back side re,--sr l Impartanf: tlVhun 0 CK: under (IIIInrg out lo(ms ySIefl-I a(Ion on the cornpuwf. f useo n f y 010 Cab .__.__ _....... ._ !__._., ...___..._..._._ _..._ _...._.._._ -__.._ _ __.._...._..-... .._,,._----. ._ ...._... .. ........ key uo move your A00,r1ss cursor do not MA u 5 t I h(; r d l a rr .__. _._ _._- --_ ._-- _ ----- ------._------- ---.._- kC,y. clly�f o✓✓r7 ;yl)le LIp Code _._. 1. systEn-1 (JWI1e( UUVUUVfO-4� rrnrn J' r.rJdross (I( Uihierq,rt from I©rallc>n} �- C11y/Town 7e ephone tNurnber B, Punlpif1q Reccord I Dale of Pumpir.)g o,I - - - --- ----- 2. Quantity Pumped -- — -. Gallons 3. CJn7f> vent. ( � C,eSSP001(s) 5c.p(ic.rank ❑ -right Tank ( � Grease -(rat �_j Olhe; (descfibe,) _----- - --------------- 4. Eflluenl fee filter presen(? [-] Yes [_ Ito If yes, was it cleaned? ❑ Yes fVo ;i. Observed coodi(ior'i of clomponenl pumped: I f. Sys _I n��pec) By ave I it c Y______ Mass 1AA9 Que ss 1AD3`1' Ve:fticle Uce.nsr 3wll� ' [_'Merpclses, Inc 7 l.cx, lion wl n s IN I <aisf used dt1, _ _... Slt nrelure of r�t,c lvlix ! ��c.ilil --- ---._—._ � J y rJr uurrctt (aciUty rcceil�l) Oaie, --- ISIOrrn4.dOC i ill I Syslem r'umOn(1 Record f�nrft;