HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 55 TURTLE LANE 4/17/2025 . COmmonvvealth of Massachusetts Town of North Andover
19) - Qa City/Town C►f Q.
b - MAY 12J2025
SYstem Pumping cor
Department
DEP has PrOVIded thitform for use by local Boards of Health. Other forms may be used, but the
information
local m t be Substantially same as that Provided here. ore using this farm, check with your
the d of H to determine the farm they use. The System Pumping Record must be submitted to
local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CAAR 15.351.
A. Facility Information
Important:when
fining out forms 1. System Location:
on the computer, C _
use only the tab
key to move your A043ress
do not
use the return Cit /Tr a�.. �r1r 4/ m" 6
key. y own _
state
2. System Owner:
Name
�►ddress(if different from krcation) -....__ �._.._.._.._..._.__.____..._
Telephone Number
_ -�- ping
1. Date of Pumping / ..m- r
Date — 2. Quantity Pumped:
43alPons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
� ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ yes ❑ No If yes,was it cleaned? ❑ Yes No
5. OWerved condition of c0"I"PUrtent Pumped:
5. S stem Pumpfe By:
J lC
N Ve�h —Number
_.
Company
?. Location where contents were disposed:
_._ .I S r
of Flamer
Signature of Receiving Facility(or attach facility ) Date
t5fOMAdoc•11/12
System Pumping Record•rage 1 of 1