HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 37 OLYMPIC LANE 6/4/2026 own of North Andover
ornmonwoaltl-i of massachusF'tts
7 (� City/Town of JUN 15 2026
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� S m in
y p
sfierr7 Pu g Rec;orci
Form 4
Health Department
(CEP has provided this form for use by local E303rds of Health Other forrras n1ay be used, but the
information rnust be substantially the s<:arne as that providers here. Before using lhls form, check with your
local Board of Health to determine the fora.) they use. The System Purnping Record rnust he submitted l()
the local Board of Health or other approving au'.hohty within 14 days from the purnping date in
accordance with 310 CMR 15,351 ---- -- _
HOUSE: fro baci< side rear I e f
A. Facility Information BUILDING: front back sine rear left, rills
Important:Whon DECK: under
lilting out forms 1. System location:
on lho computer, r B A
use 4..a" l only thn tab s14 a + l q
key to move your Address
cursor •de not MA � -
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key. Cilyl'f'own _Zi
�,tafe. Code
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2. Systern Owner:
---
r_
rN 7lT1e
Address (if ditierenl from location)
M P,
ty(1-own ,-IErie Zi
p Code
Telepharre f�lumtaer __
B. Pumping Record
1. Date of Pumpirag _.__ _1___ . _ ._ .._ ' Quantity Pura n�cj.
Dale y p" Gallons
3. Component: ❑ Cesspool(s) Septic Tank( ❑ Tight Tank E] Crease Trap
[_7 Other (describe) --- ---.---_ ______.
4. Effluent Tee Filter present? ❑ Ye/urn�')ed:
No If yes, w@s it cleaned? Yes �] No
5. Observed condition of cornponent
5. System Pumped By:
Dave Tln� Mass 1AA95E Mass 1AD31Z
Name Vehlrlr, l-ic.en;e t4uY7be!
eateson Enterprises,- Inc..
Company
7 L lion whore contents were dispose(( .
GLSD
---.-__.
Slynalrrn of fi ulor Dale
signature of Fiecewlnq I aciliry (or a lia t,h (aciliry r<;eei{ .) Da1e — -- `-_
t5form4Aoc- 11/12. Systern Pumping Record Pack 1 of 1