HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 211 CANDLESTICK ROAD 6/19/2026 Commonwealth of Massachusetts Town of North Andover
City/Town of
r System Pumping Record JUL - 2026
Form 4
DEP has provided this form for use by local Boards of Health. Other fb iq-gwl
information must be substantially the same as that provided here. Before using thi'sNoMMICtft-th 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: fronC121k side rear le righli�
A. Facility Information BUILDING: front 'rock side rear left ' ht-°
Important:When BECK: under
on the computer, y em OCat ;
flllinh out forms 1. System o (((/ti ddd
use only the tab
key to move your Address
cursor-do not MA _
use the return
key, CitylTown State Zip Code _--
2. Sy e (Owner;
rti� rya _
Name
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Address(If different from laaatian)
MA
City(Tawn Sta ,dip Code
`". -: .
Telephone Number
B. Pumping Record
1. Date of Pumping Date - — — 2. Quantity Pumped: Gallons — —
3. Component: [ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [ iVo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. CDave
m Pumped By;
They Mass 1AA95E Mass 1AD31Z Vehicle License Ni tuber
B` teson Enterprises,
Coral any
7. L ation where contents were disposed:
G SD .�._......._ � .......
Signature of Hauler Date
Signature of Keceiving`Facility(or attach facility receipt)-.--- Date
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