HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 90 LOST POND LANE 7/10/2026 Commonwealth of Massachusetts Town of North Andover
(=a City/Town of
System Pumping Record JUL 5 zozs
❑ ❑ Form 4
Health Department
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351. ------------ -----
___ _ HOUSE: ron back side rear q1eftight
A. Facility Information BUILDING: front back side rearright
Important:When DECK: under
filling out forms 1, System Location:
7
on the computer, {
use only the tab (,.�4.�
key to move your Address -- -- —_ __- __..
cursor-do not
use the return ---- -------- — --—..__ Mp
key. City/Town State Zip Code
2. System Owner
Ell-21=1112 Name
Address(if different from location)
_ MA _
CitylTown —^_ —__--------_-_--_ State Zip de --
_
Telephone Number
B. Pumping Record
-7) Vj
1. Date of Pumping e 2. Quantity Pumped: Gallons
g —
Dat
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): ----------______.._ -------------------.—_._._______---_ __ _----- __.._---__--_-
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of compon nt pumped:
6. S ste Puwnped By:
aveTin -----_---.___. Mass 1AA95E M 5s�1AD31Z '
Name ,P Vehicle License Number
_ z 'n Enterprises, inc.
Co pany
7. ocation here e n disposed:
GP SD
C7ato ------ ""` ---__
Signature of Receiving Facility(or attach facility receipt) Date
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