HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1260 SALEM STREET 6/16/2025 Torun of North Andover
` \ ! Commonwealth of Massachusetts
City/Town of JUN 16 2025
n systern PUmpincg Record
4 µ Foram 4 Health Department
I
DEP has provided this form for use by local f:3oards of Pit alU�. Othr:r fo(lra, may be used, but m
information must be substantially the same as Cheat provided here. Before using Ihis form, check will) your
local Board of Health to de(errnlne the form they use. The System Pumping Record muss be submitted 10
the local Board of Health or other approving authority wllhin 14 days from the pumping date in
accordance with 310 CMR 15.351. -----_-.---..__._--__._--
___._._____..._— _ HOUSE: front back side ar left rli'ht
A Facility information BUILDING front black ride rear left rlehl
Important:When DECI<_ Under
filling ou(forms 1. Systern Location.
oo the Cornputor,
use only thre lab — ---- --_ G'2,�7:�— +
hey to move your Address
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use the return _ l�_�.�GZ�1 `f"__—_..__ _.__._.. ..._---... n—
key. City/Town Seale. 7i Code
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,d) 2. Systern Owner:
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l,r f`l�me
nrLm `
A dress(I(difieronl from location)
MA
ly own Slab, lip Code
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TelephonL Humbert
B, Pumping Record �
1. Date of Pumping
2 Quantity P u rn p e d --L —_----------
Gallons
3. Component: ( ] Cesspool(s) ( Septic "rank Tight Tank ❑ Grease Trap
O(her (describe): ------__.-- -_-...
4. Effluent Tee filter present? ❑ Yes ( No If yes, was it cleaned? [_] Yes ❑ No
5. Observed condition of component purnpe7d:
6. System POmped By:
Dave Tlney _.. Mass 1AA95E aNS ssp IAD31Z
Namo Vehicle t ireoso Wurrl.
e�(@nn Fnferprises, Inc
Company
7, Location where con(ents wore disposed:
aLSC
t
Signalure of Hauler (Ole --
Signature of Receiving f-actliry (or attach (acili(y receipt), Dale
I5forM4.cloc. 11112
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