HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1145 OSGOOD STREET 3/13/2025 Commonwealth of Massachusetts Town of North Andover
City/Town of LLB
StOM Pumping Record R 2 7
Form 4.
CDEP has ProvidedthitfOrm for use by local Boards of Health. Other qMent
the
information must be substantially the same as that Provided here. Before wing this form, check with your
local Board of Health to determine the form they use, The System Pumping Recordthe m
I Board of Health or other approving authority within 14 days from the pumpiust be submitted to
ng date in
accordance with 310 CIV IR 15.351.
A. Facility Information
When
filling out forms I. system Location:
on#*computer,
use only ft tab
key cured-do nve ot r Ad
dreas 3"ki
use the return 1
key. ChyJTo wm
___---.�._...�.._...�._ _
2. System Owner state ZIP Code
—dreas in anterent from iocatlonF—
TiWPhone Niltyber
B. Pumping Record
I. [date of Pumping
Date " 2. Quantity Pumped: �
aflo'��
3. Component. ❑ C+esspot)I(s) Septic Tank
Il Tight Tank ❑ Grease Trap
C7Other(describe): —
4. Effluent Tee Filterpresent? ❑ Yes El No If yes,was it cleaned? ❑ Yes ❑ Igo
5• Observed condition of component pumped:
6. system Pram By:
..
ehicie t.acense�tJ r
C+prnpany
T Location where tents were disposed:
re Or Hauler =.:
Date
Signature of Rewiving V' (�cl 1ereipt)
.doc*11/12
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