HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1635 OSGOOD STREET 5/20/2025 Commonwealth of.Massachusetts Town of North Andover
co'lCKY/TC►wn'of ,a � MAY 2025
System Pumping Record
�► Health Department
DEP has provided thitfarm for use by local Bards of Health. Other
form in must be substantially the same as that provided Mere. Before u�may be usc�t, but the
locathe localI of H to determine the farm they use. The System Pumping Ord must be submittk withed to
Board of Health or other approving authority within 14 days from the pumping date in
accOrdanCe,wlth 310 CMR 15.351.
A. Facility Information
bnporturd.-Men
fitlhV out lbrms1. System Location:
on the mmuter,�
use only the tab IV
key mme do
do your Address
cursor• not
UzeV3.#
key. City iT.n
state -- ___.�__... y Cede -- --
2. System Owner..
Nam
( different frarn ltacation} _.___._ _
13-
u PIng Record
1- Date of Pumping
Date 2. Quantity Pumped:
3. +C.°on
tponent; [j Cesspool(s) ❑ Septic Tank
❑ right'Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yeas ❑ No
If yes, was it cleaned'? Yes El No
5. Observed,condition of cwqxnent pu .
6- System Pumped By:
Na ._,
Vehicle Lloeffla --
fdumber
Convany __-
7. Location Whens contents more disposed:
of ReceMnq h+for attade tacitky
trrtM.t�C+11/12 i
System IPunVing Record•Page 1 of 1
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