HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 183 VEST WAY 5/2/2025 Commonwealth of Massa own o North Andove
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SYStem Pumping Record MAY 12 2025
P has Provided tNtfarm for use b local i-e @nt
in m be s Y s of Health. Other farms may be used, but the
k��l of hearth�detemne substantially the same as that provided here Before using this farm, check with your
the local Board of Health or outer the farrrt they use. The System Pumping Record must be submitted to
approving authority within 14 days from the pumping date in
accordance with 310 CHAR 1S.3S1.
A. Facility Information
>gnkv out forms 1, System Location:
key to resa
Mnor n
use the ret um
key. cI.yrrown i... ar
state YIP
2. System Owner.
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GL
tIIdifferenk
Wn
ink ordd
1, Date Of Pumping
rsa� 2. Quantity purrtit +d: � :.�
3• Component: a _ _.
❑ P001(s) Septic Tank ❑ Tight Tank
❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter presero ❑ Yes ❑ Na if es, was it cleaned?
Y ❑ Yes ❑ No
. Observed,condifiorl of comporwnt pumped:
S• S etn Pumped By:
� vehicra Lkftse Number
y
7` Localjon wtWe cOnWts were disposed:
AID of Hauler --
of raCMW(or f�acft receipi)— pate-` -
t WW-doc•11/12
Sys Pumping Record•Page t of 1
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