HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 72 STERLING LANE 6/16/2026 �L\ Commonwealth of Massachusetts Town of No�ti Andover
City/Town of JUL - 7 2026
System Pumping Record
Form. 4 Health Department
DEP has'provided
provided this form for use by iocai Boards of Health. Other forms may ue used, but.the
info"ation must be substantiialiy the same as teat provided here. Before Usir!z-e this forrr, check Wfth your
local Board of Health to determine the form fty use. 7he Sys ern, Pumping Raccreal must be submitted to
the loca' Board of, Health or other approving authority wjii,,; . 1 days from the Dumping date in
accordance with 3,11 0 CMR !5.35i.
A. Facility Information
lffmartm*When
ftng o"t forms "I- Systern Location:
on the=rputer,
use or,E r the tab
key to rn*ve your Address
cursor-do not
use the return MA
key- Ofty�' M'—e ZP Code
2. System, Owner:
Name
Address(7.1 arrs-sn't Imm 10'--ton)
VtyJ�awn state Ylp code—
B. Pumping Record
D2tc of Purnming Ito ao
Oats I Quantttty purnpaid: A '
cesspcoi(s) an
:
9
Grease Trap
Other(describe):
4. Effluent Tee Filter preserj�L?
Lj YeA�,' No i�yes: Was cieared?
Yes 7 Na
5. Observed cOrldit'On 04 component purnped:
rl! '--nation is vain on!Y atpu: A fl of this estimated
C-- System, PurrP e d Bly: riot respe-sib?e be and 1-he date above.
!Vefzle
j&S DeV6;00r11er7t. d1bla
C
7- Location.where ontenter -------------
Were cilapoeed:
Stcrwax'-Fr.Global xnviror,
20 So. Mill St Mentai, Li
0
r S--e abovc-
above
t&FO?M4-do*-11/12
System Pu!-'Pr G Rscord pace 7 of 7