HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 20 COLONIAL AVENUE 5/14/2025 Town Of North Andover
Commonwealth of Massash[,�setts
c
C i t y -Town of SAY 15 2025
a° System Pu
mping umping Record
Farm d Health
DePartMent
DEP has provided this form for use by local Bowds of Health, (')ther form s may be used, but lhre7
information must be substanhally the sarne ras.> that provided horn. Before; t.rsincl Ihis form, cheek, with youf
local Board of Health to deterrnirhe the form lhray use 'f the System Purnping Record must 0P subrrhMP(.i t(r
the local Board of Health or other apprr`nrir) ) autlhorfty within 14 days from the purnping date io
accordance with 310 CMR 15 351
H0fjSE: (!] o5 back aide rear``~.:::,:.:. riphT.
A. Facility Information BUILDING front bark hire rear left ril,I,t
mportant: Whore DECK: nc,)er
Mlhg out forms 1 System Location:
on the cornputol,
use only tho t.a t7
key to move your Add(e s
cursor-do nor (�use the return MA
Key, City(Town SIaVe Zip Code
r:7. Systern Owner:
w r
Address(If different f(orn location)
MA
Clly/70m) __.__ ............. plate Zip Code
Telephone>, r`lur,�ber
B. Pumping Record
1. Date of Purnping 2 Quantity P rmped __... -.._-_--
alions
3. Component: ❑ Cesspool(s) _j Septic rank __] 'Fight Tank ( J Grease Trap
Other (doscribe)
4. Effluent 'Tee Filter presenl? ( ..) Yes � rj0 If yes w4;as it cIer�n0(,? [�] Yes O n
5, Observed conditlo of co-r,nponent pumped:
6. System Ptamped By.
Dave TIney Mass 1 r 95 Mass 1FiD31Z
Name V.hlCle Li
C lurrtbr r
eafenn EnlPrprisos,_Inc
Company
7. Location where contents were disposed:
Sigrialurr? of Hauler Oais,
slgname of R.ecelv)ng V acility (ear attactr facililgr (r,ceipi) 0 ( ,
I6form4,doe, 11/12 `3ystef-n Pu n"Ping Record Page 1 ref .I