HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 329 REA STREET 6/4/2026 Town of Nor[hAndover
C;ommonweah�-) of MRssarhl_a setts
I � Yr
Clty/7 own of
JUN 1 2026
System Pant ir7c R�r
y o r c�
Form 4
Healthy Department
[)f~P has.> provided this forrn fOr use t7y local Boards of I{oalth Other furrrrs r-nay be, used, t,ut tlie,,
information must be substantially thrl same. as Mat provided here, Beforc; using this form, c1ir1ck will,l yr,rur
Vogl Board of Health to deterrrline they forr-n lh ey use The Syst(-yM Ptjrrlpif cg Record most be suhrnittr(t to
the local Board of Health or other approving au'hc',niy within 14 days, fmn-) the ptlnnping riato in
accordance with 310 C:;MR 1 5,3)i
--
_ tlOIJS` `fror't side r� tir f� �ipht
A. Facility Information E�>t_�IIt.CINC,� ont r7rrck side rear Irrft rq)hl
Important:When DECK: under
Puling out focrns 1. System t._occltlon
us(he cornpiuler,
tt ��y r
SO only tY7c� tab
key to move,your Address
t ut,or-retnot 'f MA
he reaurn __ _._._ ____ _ .--- _ -.__ ,_
key eiPyfT"own SI3Ie 7,ip Cody°
- 2. System Owner
ran sr
f. N�rnr
Adclrcr.>s (If different from locatickn)
MA
C;ity(l own _ _.
Zip Code _
.w .. )
Te ephone Numb"(
B. Pumping Record
GG
Date of Pumping C3eir — — 2. Quarnfity Flurnper,:1 Gallons
3. Cornponent ( ] >rsper>I(s ) Septic -Tank [_�_J Tight -7 ank ❑ (;grease. Trap
t'_j Other (descrlhis)
4. Effluent Tee Filter present? ���� Yes __-] NC) Pf yes, was it clearsed? (_1 Yes [`J Pdc1
5. Observed condition of component purnped:
__.._
6, Systens Pi,imper_I By:
Dave _1IneY - T Mass 1AA9;5 E Mass 1AD317
Name, \/nhic lr Lu,e:r�ti r� rJu r�Lier
eatnson Enferprlses, Inc,
Company
7 L . ion where contents were dispo,;�rt1
GL5L
I rlGlt,, I }`.{aUEyf I.)ate
Siynalurr;; of Receiving Facility (or ltnch (»dirty reoe�{'>.) a(e
i5fortnM.doc, 11/12 System Purnpincl Record Pane 1 of .I