HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 953 JOHNSON STREET 9/3/2026 Commonwealth of Massachusetts Town of Nofth Andover
c City/Town of ___ P 202
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System Pumping Record
Form 4
`- }T Health Department
DEP has provided this forrn for use by local Boards of Health. Other forms may be used, but the
information must be substantially the sane 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 subrnitted to
the local Board of Health or other, approving authority within 14 days from the pumping date in
accordance with 310 CM 15.351. rea__.._-_.__....__--.-_-`-
HOUSE: front back s I d e r left r Ig ltit
left(r,.
A. Facility information BUILDING: front back sick rear le its
Important..When
DECK: under
filling out forrns 1. System Location:
on the computer, To use only the tab
key to move;your Address
cursor-do noh
MA
use the return d ' _
key, CitylTown Slate Zip Code ----_.___._._
?._ Sy stern sternwner:O
Hart e
Address (if different from location)
MA
Cily�fown State ode
Telepf7on� Jurnber
B. Pumping Record
1. Date of Pumping ---- -- - ------ 2. Quantity Pumped:
Date Galt ns
3, Component: ❑ Cesspool(s) eptic Tank [l Tight Tank ❑ Grease Trap
E-] Other (describe)-, _..__.____..__._.__ ___.__—__ ---_____ _.--_-...
4. Effluent Tee Filter present? ❑ Yes G o If yes, was it cVeaned? ❑ Yes C7 No
5. Observed condition of component pump d.
6. Sy � em Pl,t peel By:
D v e 1_i n ey _.._----------__-.. Mass 1 AA9 5 E Mass 1 A.D 31 Z
N me Vehicle License N mber
B n�Enterprises, Inc
Company
7. ocation where contents were disposed:
'GLSD
5i9 ire of Hauler Date
Signature of Receiving Facility(or altach facility receipt) Bate
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