HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 793 FOREST STREET 6/17/2026 �L\ Commonwealth of Mass.achuses Town of Noti Andover
Cit Frown of VA�e-r
System Pumping Record JUL 7 2026
Form. 4
DEP has provided this form for use by loca" Boards of H but the
information must be substaritilefly the sarne-as that.provid-P- hefe' Pit -"N *, -check Wfth your
local Board of Heath to determine the form they use. T he System PLimping Record must be submitted to
the local, Board of Heafth or of-her approving authorlry,WH fin '14 days Proms ohs Durnoing date in
accordance wft 310 CM R 15.3 5,1.
A. Facility Information
Impoftwitwhen
ffC q out forrm, 1. System Location:
on the=Mputer, Ota.....-Gcxa-5�-,
use oniy the tab
key to move your Address
cursor-do not
use tfte return
key- ZP Code
System Owner
IL AV 2LLL, ('"V-t--4�to-n
Nar
Address(1,d'.. . r.t-Om joczafor�)
C.ty7own
Zip Code
B. PumPlng Record
000
OatLrr of Rumping
oats 2. Quan;44Jtv plumpa-d:
Cesspool(a)
-q
7' Grease Trap
Other(describe):
4. E-Fluent Tee Fifter prese:,Z
yes
KIN Yest WaS iZ Ci6ar-ied? 17 No
5. Observed Corjd; Or
OT Ccrno
on,
of this estimated
dot.resp-C."nsibiebeyand the date at2ye,
..!p d By:
/7
j&S Devebprnnen� d1b/a ste"'Varts Sv#atc
7- -----------
-'Its W--re 6japosed:
above
Date