HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 479 LACY STREET 5/6/2025 Commonwealth of Massachusetts Town of North Andover
SYstOrn
quiv city/Town'of
Pink MAY 2 9 2025
that Hforms May
ealth
Ltd of Mfg to ti using this form, check with your
the local determine ppr f¢r�rrn they use. The System Pumping R d "tir us�t`be submitted to
f�a7it of 10 Health or other wing authority within 14 days from the pumping date in
with 310 CRcIFt 15.351.
A. Facility Information
Nnpsnt:When
fainq out ftww 1, SY'StSM Location:
on dre computer,
Wy to Move your
0WW_do not
use the return
key. dY/town' __ -- tN
state
2. System Owner.
Nam
Arid (N from )
------------------------
Code ..
r
u
1• !Ste ofPuna C � _ tuan
_ -- tity Pumped:
❑ (e) Septic Tank C Tight Tank grease Trap
0 Other(describe):
4. EMWnt Tee i~iit" nt7 0 Yes 0 No if yam, -----Y..�__
�cleaned? � � 0 No
5° Observed4ondifion of corn rat pumped:
6- Sylstern Pumped By:
y - --
7. LocagOnwhere contents were disposed:
dear ._...,._....._.....��._
FaC (r'Mach fey
---_ _
Wwv
ort.r 11/12
System Pur ving Record Paps 1 of 1