HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 86 SHERWOOD DRIVE 5/9/2025 Town Of NOrth Andover
` Commonwealth of Massachusetts
City/*iown of MAY 15 2025
System Pumping Record
� � ✓- ,> Fort Health DepartMent
DEP has provided tNs form for use by local Toads of Health, Other lor'rr)s may be osedi but the
information rust be substantially the sarne, a,,s that provided herd. l3efore.; using this form, check with yom
local Board of Health to cleterrnlne the fora"1 Ihey use, �f'hp System Purnping Record n"Ust be submitted (e)
the local Board of 1---lealth or other approvin(,) authority within 14 days frorr1 the purnping date in
accordance with 310 C'MR 15 351 ___—._--- __..
--__ _ _..__ .— HOUSE ron back side rear eft rf}ht
A. Facility Information BUILDING, front back side rear left rif,h(
Important; When OFC.K der
Mling out forms 1. Systern Location
on the cornp tef,
use only the tab
key to rnove>your Addr ss
cursor-do not
use the return _ __.._____.�_______.__. _.__._._. ..._. _._ MA
kay. City/Town _.___ Sl<{j.(_._.___.�—........_._.._...._.__ Zip Code
7 System Owner:
L11-1-:1:AM`K
Address(If different from location)
MA
Clty/Town ;I ate Zip Code
elephone Number
B. Pumping Record
1. Date of Purnpind _______.__ _ _____,__ 2 Quantity F�umped
Cale Gallons
3. Component: Cesspool(s) j ] Septic -Tank n '1`icght Tank [ Grease Trap
Other (describe): __ _.. f._- _._........_
4. Effluent Tee Filter present? C ) Yes YJ No If yes, was it cleaned? [. .� Yes o
>. Observed condition of cornponent purnped
6, System Pumped By.
Dave T I n e I _—...--..__....__---..__._....__. f'�9 M ass 1 A D 31 Z
Name3 V hfcle l.iCe?nse Jun7ber
Bakeson Enferprlses, Inc
Company
7, L.ocalion whcrc contents were ctispasr°d:
6 L U
il-3-1)
Signature of Nauler Dale
_._-_._._____._-.-_____ __._ _.i- _.__-.
5lgnalure of Recelvinc� f-:acility (or attach fa¢;ilily rec;oipf) Dale
lSlorrN.dor,, 11112 `,;ystern Pumping Record Pale 1 or t