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HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 155 CHRISTIAN WAY 6/16/2025 Comn-lonwealth of Massachusetts Town of North Andover City/Town of _ 0 == JUN r -iV System Pimping Fecorci _ 3 Form 4 Health Department DEP has provided this form for use by local Borards of Health. Other forms may be used, odt Ifhe information must be substantially the same ns lhat providers here, Before using Ihis form, check will) your local Board of Health to de(ermine the (oral they use The System Pumping Record m(.Is( be t>ubtTllt`ted (0 the local Board Of Health or other approving authority wilhin 14 days from the purnpinp date in accordance with 310 CMR 15.351, HOUSE: front back side rear left riflht A. Facility Information BUILoltvc front hack side rear le{t rif; hnportsnt:Whoa DECK unc)er (Illing out forms 1. Systern Location, on the computer, use only(ha lab key to move your Address cursor e do nont (� fV A use I h e t©tur —--- ------------—--- __ —`___---- —--- -- 0 d—e - key, City� — fown slate— Ji-p--Code 2, System Owner: ir( N a rn E —_—_-------- —... __ _— ----...------'-----_..------------ --- ----.----.__Address(If different from localion) MA ty own stale Zip Code Telephone tVurnbe;r B. Pumping' Record 1. Date of Pumping 2. Quantity umer .Dal _------- Gallons 3. Component: [] Cesspoal(s) ( Seplic faok ❑ Fight / " Tank (] Grease Trap ❑ other (describe): --- ------ ___-._. 4. Effluent. Tee Filter present? ❑ Yes [_) No If yes, was it cleaned? Yes [] No S. Obse��rve..��d,,condition of component pumped; 6, System Pumped By, Dave Tine Mass '15D Mass 1 \ 3'tI --�_—__-y __.-_- _. __...__ . __ _ ________-_ _ --- Narno Vehicle Licn_nse t`Jvrnl er 2gf@mn �nigrprises, Inc. Company 7, location where con(en(s were disposed: -....-- ' --- _ _ - -- l'� '-------- - Slgnalure of lI er Dale Signature of ftecelving Facili(y (or attach facility(eceipt}, Gale ---"��-- If�(orrnel.doc' 11112 Svste'rr) Purrini(n R—,,,,i . I)""- .,