HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 135 LACONIA CIRCLE 4/24/2025 Town of North Andover
c` Commonwealth of Massachusetts
! �= City/'Tovvn of APR 2 8 2025
System Pumping Record
Fc)rrn a Health Department
DE P has provided this form for use by loctll B08rds of V tealtlh. Other fc.7rrn s may (.ised, bu the
information must be sr�,bstantially the Same as fhrat far(',)vided here. Bpfore� r.as,ing This, forr-n, check with your
local Board of Health to determine the forn`I they use,. The Syster-n Pwnping Record n'tu st be subinittecy Ir,>
the local Board of Health or other apptoving authority wlfhin '14 days from the purnping date it)
accorda0 ce with 310 CIVR 15.351
HOUSE front back side rear eft jr(ght.
A. Facility Information BOIt.DING front hack c,Ide rear left (if:h(
Important: When DECK: under
(Illing out forrns 1. Systern Location'.
on the corr7putor, / �s____
use only the tab t' C c` !p 4
key to rnovca ynr.rr Addrr ss
cursor-do raol
a
use the return _ ____ 5 -__..._---- _._-- -----..._. _.._— _-- MA _ ----
Key, State Zip Code
'+- 2. Systern owner:
name
Address (If different from location)
MA
Clty/?own Sf air Lip C'odn
olephone Number
B. Pumping Record
'1. Date of Pumping __Y_�"_e! 1~' ._.--.. ...___. 2 Quantity Purnped .__.. _____....._
-5Ir, Gallons
3. Component: cesspool(s) Septic Tank [-j Tight Tank Grease Trap
[] other (describe); _ .. _.___ _------------- ____
4. Effluent Tee filter present? [_� Yes NO If yes, was tf cleaned? (_ j Yes �_� No
:5. Observed condition of orr7ponent purnped,
6, System PGjr-aped By:
Mass 1AA95Ew Mass 1AD31
Name Vehicle License. Nurrrk r
2efew Enferprises, Inc__
C,Ornpany,
7. t cal n where contents were disposed.
Ct_SD
Slgnalure o I
- _-._..-- --7- _- --- - __. ----
Signa(ure of Recelving F=ac,ility (or attach facility receipt) Crate.
tfformzt.doc, 11112 SYS(ern Pumping Recor(P 6.yat e 1 of 1