HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 970 JOHNSON STREET 6/19/2026 Ccimmonwealth of M s�chuse�tr Town of North Andover
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L 6 2026
System Pumping Record
�c\ 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 thro same as that provided rlefe Before using lhls forn), check with your
focal Board of Health to determine the form lhey use The System Pumping Record must be submitted to
the local Board of Health or other approving awhority within 1/1 days from the pumping date,if)
accordance with 310 CM 15 351
— _ HOUSE front ch")CI),
Side re�1r Ieft rlP�ht
A. Facility
irl fCJrf1"1atIC7r1 Ell lJII.DINP,: front Paec!( yule rl.ai IC� T rif),h(
mportant:Wien D CK: under
rlllifIg out tocrns 1. System Location
rrn the computer, °1
uSs only t)ie tab
key to movr>your Addross - -
e msor-do nol MA � m
use the re turn --- __.___ ._. ._-.._
Cilyfl own SI'zlr ._ __ _ _._ __._ ----.- _
kcay Zip Code ... _..
2.. System Owner
---
nan
Address (if different from location) - ---
__ MA
CityfTown __-...
- - — _- — - -- -- --..-_._
FIEphone tJurr7ber
B. Pt_arnpitig Record
OaIE. -' . _.._. C
1, Date of Pur7�ping - -\. . .. 1 Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) (_ Septic Tank( (� Tight Tank ❑ Grease Trap
Other (describe) --------- -----._-
4. Effluent Tee Bitter present? C J Yc, J No If ycrs, was It c�•Is>ane,rl7 (,� Y�;> No
5. Observed condition of component urnpaed:
6, Systern Pumped By:
Dave Tlr)ey Mass 1AA95 Mass 1AD317_
_-
Na1Y1e \/eY'ilf In l.icr:�rr",c"Nur"r p)rr
eateson Enterprises, Inc.
Company
7. C n w h ere- contents were aisposett:
G L9", )
�iyns -isuler Dale
------.__. __- — .
Signature U eceivfnq <'.rci ity (or all rcY, facility (c.cei{).) C.1r+le
t5forrm.doc, 11/12 Sys>tern Purnping Record r'acge 1 of 1