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HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 169 JOHNNY CAKE STREET 5/9/2025 of Commonwealth of Massachusetts TownNofth Andover City/Town of MAY 15 2025 System Pumping Record Form 4 Health tr Dep DEP has provided this fore_) for use by local Boards of Health. Other forms may a be Mqlt the Information must be substantially [he same as that provided here. Before using this form, check with your local Board of Health to determine the form they use, The System Pui-riping Record must be submitted to the local Board of Health or other approving authority within 14 days from 'he pumping date in accordance with 310 OMR 15,351, rig HOUSE: front back sic] rea A, Facility Information BUILDING: front back side nlporlaot; When DECK: under filling 0111 (OfMS I Sys end, Locatior on Ihe cornputef, use only lit©tab key to move youf Address cursor -do not �UAtIAAII M A _ 0A use the return �L__ __ _ _..__ --I __— key, Chyfrown Slate , ------- Zip Code -------—-- 14 Q_ 2. S tern Owner mun Add(oss (if differont from locailon) MA p_Code A� B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped. Gallons 3. Component ❑ Cesspool(s) &_6�epttc Tank ❑ Tight Tank El Grease Trap Other (describe) 4. Effluent Tee Filter present? [] Yes No If yes, was it cleaned? E] Yes No 5. Observed condition of component pumped ----------------- 6, Systen-i Pumped By Dave Tine MasslAA95E Mass 1AD31Z Name, Vehicle License Number Baieson Enterprises, Inc. Culnpany 7 Location where contents were disposed (3L5D -7 _§is;-nature-of-1-4aulet _Ua te > , _,2 Ignature- -- f-Re-ce__-v in-g-, a-c--1 it ----- . p)v ,cci t Date System Pumping Record Page 1 Of I