HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 70 SUMMER STREET 6/15/2026 �L\ Commonwealth of Massachusetts 7bWn c)f Nor ll Andover
System Pumping Record JUL -t 7 2026
Form 4
alth Dep
DEP has provided this form for use by locei Boards of Health. Other forrrs may be ,, gWnt
irrfornnationrn- ust.be substantiaHytthe sans as that provided here. Before using ttis form, check with your
local Board of Hezith to detenins the form they use. 7he System Pumping Record must be submitted to
-h
the local Board of, Heath or cf-ther approving aut 'orty �'W�hln 1,4 days from the purnming date in
accordance with 3-10 CMR 15.351.
A. Facility Information
impart When
f Ming out tarns System Location:
on the oornputer,
useor,,Iy the tab --1,CD
key to move your Address
Cursor-do not
use return
key- Zp Code
2. system, der:
Address 07 dfffe'rart
sr e Zip Code
eiepncne Nurn6w
B. PUMPIng Record
ate of purn - 5
Ding
Date 2 Qu Pu-, o
"and E"I ''.grit Snk —i ,,' Grease Trap
-1 Other(describe):
4. E-Muent"reeFijterpresent? y
No i yes: Was iT deaned? 77 v s 17 No
Observed co tOn 0. m Ponsnt purn. psti:
Of tl eStfrrated
is. system U BY-
'dame
I (--�7
%
Urr
LiCen$a Nbs,
j&S Deveioprnerr.
7. Loa2don Where=Mtsrta
Wem dispcsed:
stew2rts ta
20 So. Mi -virOn—On i, LLC
gzradford, MA 0 1 as;s
s-,9r-atUrs O HavIer —C, rmt cv_=
bove
t5ftnT:4-doc-11/12 at--'-cil-ty reoelp*
ate
System:Purnp G Record.pa,qe 7
of,