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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 141 STONECLEAVE ROAD 4/18/2025 Commonwealth of Massachusetts Town of Nofth Andover APR 2 8 2025 City/Town of System Pumping Record Form 4 Department DEP has provided this form for Use by local Boards of Health. Other forms may be used, bLji the information must be substantially the same as that provided here. 9(--,,fore using lhis form, check will) yow iocal 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: front (a 2c ', rear left,side ( A. Facility Information BUILDING: front back side rear left right Important; When DECK: under filling out forms 1. System Location "U" on the compuler, use only the tab key to move YOW Address cursor-do not use the return --- MA --- key. Zityr-'own Zip Code 2, System ner: Name Address (If different from location) M A C[tyrTown slate Zip Code Telephone Number B. Pumping Record X'6f 1, Date of Pumpingaa(e 2, Quantity Pumped: -��a I I o—ns 3. Component: ❑ Cesspool(s) Septic Tank ❑ 'Tight Tank ❑ Grease Trap 0 Other (describe), 4, Effluent Tee Filter present? 0 Yes -1 No If yes, was it cleaned? EJ Yes 0 No 5, Observed conditioncomponent m f nt P ped: 6, System Pumped By: Dave TIney Mass 'IAA95E 7'931Z ass s Namo Vehicle, License Nur<hfer! gnfescn lnkclrprigos, Inc. Company 7, Con where contents were disposed 'ignalufe of Hauler Date —Signature of R ,qecelvl� 'Fa—cii-lfyFol—atlac-h-fad-iltvy-fecei-receipt) b —------- Date WDM14.doc, I'M2 System Pumping Record Parjn 1 or,I