HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 707 JOHNSON STREET 5/15/2025 _ \ Commonwealth of Massachusetts Town ofNorth Andover
7 r City/Town of _ --
System Pumping Record MAY 30 2025
Farm 4
Health
DE 9spP has provided this form for use by local Boards of t-ieallh, Other forms rna�y bet,� ec, ut 111pnt
information rnust be substantially the same as thrat provided hero. Before using this form, check with your
local Board of Health to determine the forrn they use. The System Purnping 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 back d e rear I e ft
A. Facility Information BUILDING: front back side mar left rif;ht
linportant: When (BECK: ndr?I
rllling out forrns 1. Systern Location
on the compuler,
use only file lab
key(o movr� your Address
cursor -do not use the return —�` �`5�+v---..__._--- ---- __..------ MA— — � ---
key. Gity(rown Stale Zip Code
2. System Owner:
hn C.`-Aj W c/4
!game
urcrn �
Address(If different from location)
MA
C If y/Town d a l e
Zip Code
Telephone Number
B. Pumping Record !t
1. Date of Pumping � I-� ----- 2. Quantity Pumped. "� ----------
Dale Gallons
3. Component: ❑ Cesspooi(s) ( Septic -tank ❑ Tank'Fight
g ❑ Grease Trap
❑ Other (describe) ._-
4. Effluent Tee Filter present? [] Yes ( AJ N If yes, was it cleaned? ❑ Yes No
5. Observed condition of component purr-sped:
6. System Pumped By:
Dave Tlney Mass 'IA_A96E Maw AD31Z
Name Vehlcle License Nurr b —�
e�few Enter rises, Inc.
(:o(npany
7, Location whore contents were dispos,cd:
Gl S
Signature of Hauler Dale
Stgnalure of Recelving Faci{ity(or atacl facility receipt) Pate -- - " `---- ---
15(orm4.doc- 11(12 System Purnping ReCOW Paget or 1