HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 31 TANGLEWOOD LANE 6/16/2025 an of North Andover
�'Lv Comn-ionvvealth of Massachusetts&ty/Town of JUN
s 2025
S stem Pumping Record
a p g Hiaalth Department Form
DEED has provided this form for Use by local Boards of Health, Other forms may be used, bul the
nformalion rrlusl L)e substantially the same as fhal provided here. Before using this forn7, check with yor
local Board of Health to deterrn'ine the form (Prey use. The System Purnping Record rnust be submi(�ted h
the local Board of 1-iealth or other approving authority within 14 days frorn 'he pumping date in
accordance with 310 C M R 15,351,
--..- ----------_--.._—..----.-__.-_-__.-_--
HOUSE: front back side rear left
A. Facility Information BUILDING: front back side rear left
Important:Wherr
DECK: under
fllling out torms 1. Sys(ern 1 ocation
on Me, cornputef,
use only tho lab
key to move your
ur Ur ss ��
Csorof do not � MA \ J
U 5 e I h c r e l u I r I --. --i- _._... — -_. ___._. --_ ___ _—
key.
Cuy�l`own Blau zip Code
2. System Owner:
Q ►-. ° ale
4 Narne
1 _ _._._
r�nurn '
-- -- ---—--__ .-.-- ---- --------- -
--- -- Aodross (II oiffe(onl ((on) location)
M_R, _
Cfty/Town Seale _- ---- '�ipCode_- ---_----
�° 7
54
Telephone Number
B. Purrping Record
1 Date of Purnping -- - —` -- ---- 2 Quantity Pumped'. ✓j G
Dale Gallons
3. Component: ❑ Cesspool(s) Septic -rank ❑ Tight Tank ❑ Grease Trap
[ } Other (describe): _.__. _ _ _------- _.__..
4. Effiluent Tee Filter present? ❑ Yes. ' �No If yes, was it clen�ned? ❑ Yes ❑ No
5 Observed condition of comf)onenl pumped:
6. Systern Pun-tped By
Dave line Mass 1AA95= Mass 1AD311....w,w
fJarrre Vehicle Uc rin jrr`rber
F3Files0n E f7ter rIseS, II
Con„piny
I Location wheie, contents were disposed.
-._ _-_ ___._. _ _._ - -- ___.__..-..'
Sign' of iidUl(;r Date- --
Siynalure a( Receiviny rac'dlly (a{ apaclr facility receipt} Date — -- --
51or i4.doc 111t2 Syslem Pumping Record page 1 of