HomeMy WebLinkAbout- - Septic Pumping Slip - 720 FOSTER STREET 8/11/2026 4e4
Commonwealth of Massachusetts ®wrl North Andover
x.: City/Town of
System Pumping Rer,�ard02.6
F or m 4
: Y �-
DBP has provided this form for use by local Boards of Health. Other forms may e s*PAI fit
information must be substantially the sarne 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 roust 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. _-...-.- - -- - -
r left HOUSE: fr�i back side rear left rl
ght
A. Facility Information BUILDING: front c side rep e t 'T;
Important: When
DECK: under
filling out forms 'I, Systern Location:
on the comfouler, 6 e 0 - �,✓"
use only the tab ---_..__._
key to move your Address
cursor-do not MA _
usethe return ..___.._..... __----- ._. _ .---_—.._ ...._..____ --..__..,._ ___----
key. CityTown State ----___._ _.___— Zip Code
2. System Owner:
Name
I I rattvn �f/ j
Address (if different from location)
MA
y ------
slat _ __-. ---__ --- ___—�._.._.__-_—_-----_.....
----- '- 4'r�^" 71p Code
Cll /Town e
Telephone Number
B. Pumping Record
1. Date of Pumping -_____---------__...._......__ 2. Quantity Pumped-,
DateGallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe); _._._..__._..__._____-----_..___.__...___......----___.___._..,_.---____._.._,._.._..._
4. Effluent Tee Filter present? [] Yes If yes, was it cleaned? ❑ Yes [j No
5. Observed condition of compo ent pr1pe
6. roped By.
Dave Tine `' Mass 1AA95EQf\AassD31Z
(Jame Vehicle license Nu
B 4_-- ter prises, Inc_
ompany
7. o Sion where to fiCwere as"ed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility(eceipt) mate
t5form4.doc- 11112 Systern Pumping Record •Page 1 of 1