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HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1000 JOHNSON STREET 6/16/2025 I : T®wn of'Vorth Andover - Commonwealth of Massachusetts �U :... N Z 6 2025 = i , City/._t_own of =1 7 System Pumping Record I-Ilth J Form 4 part ,ht DE P has provided this form (or use by local £3ofar(.Is of He tllh. O(t)er four)s rnay be, used, but (he information must be substantially the sarne as llaat provided hens Bcforra using this form, check with your local Board of Health to determine the (orm they use. The System Pumping Record mt.,s( be submMC10 to the local Board of f tealth or other approving authority within 14 days fror-n the purnping date in accordance with 310 C M R 15.351, — ---------.---__-----�—-------..-_._.---_. _._ -. _ HOUSE: front bac Y side rear left ri-h� ----- --------------------------- - A. Facility information BlJll_DlNG1 front hack side rear left right Important:When DECK Under (Illing out forms 1. Systern Location. on the cornpuler, use only the lab CU�Ce"'"�'✓� �/'\ ✓' "/ key to move your Ad n r ss cursor e do o( use 1 h e r e hu t n ._____`i---'-i-d� s.��.___—. __,.--._ __. . .._ --- _ _____---�_ ------ ---------_ �._.._----------.....- key -ItyTrown slate zip code 2. Systern Owner )l.Y mama Address(I(dil{er©nl from Iocaiion} MA Clty/Town Sia(e lip Code Telephoriry hlurrYber B. Pumping' Record 1, Date of Purnping C?uanfity Pumped. Gallons 3. Component: Cesspool(s) Septic Tank ❑ 'fight Tank Grease Trap R O(her (describe) -- - - — ----- --- - - -------- I. Effluent Tee Filter present? [-_) Yes/,"I"Cd hJO If yEe`,. wz:) it cIe�)r)eC1? [-] Yes l_J No 5. Observed condition of component p 6. Systern Pumped By Dave Tlnay__— Mass IAAc-) ass 1A 1Z NJ -- m© Vehicle I enso Nvm r t3gLow Enfer rises, Inc_ _ Company 7. 'afion wfaerc con(ents were di5po5cd: �fgnaww of mauler L7ale Signature of Recee ving Facillty (or attach facility receipl), bale I£liorrM.doc' 11112 Svsiern fl,rrviinn