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HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 95 CARLTON LANE 6/24/2025 Town of North Andover Commonwealth of Massachusetts City/Town of JUN 3 0 2025 System Pumping R ecord Form 4 Health Department DEP has provided this form for use by local Boards of Health, Other forms may be used, but the information must be substantially the s2rne is that provided here. Before using this form, check wilh your local Board of Health to determine the forrn they use The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from she pumping date in accordance with 310 CMR 15.351, —------------ HOUSE. (,,,fjqn) back side real, left' A. Facility Informatior-i BUILDING. front back side rear left riE Important: When DECK: u n cl e r Male g outth oe tab I, S\/stenn LO ationoy the cornpulef, __ _ , _ key to move your Address cursor do not CA Use [he return ---------- k e y CHY/1 O-n Zip Code 2, Systerr� 0 w n ef C')c L1I 1—11: Naf--n e ------- Addr©ss (If different ron­)-1-O-C--ai­1-Q--r1--)----------- ...... MA cllyrrown State Z, Zip Code Telephone N umber B. Pumping Record 1. Date of Pumping -Dale-0 Quantity Pumped'. Gallons- 3. Component: ❑ Cesspool(s) j�Septic Tank El Tight Tank 1-1 Grease Trap Ll Other (describe) ------- --------------------- 4. Effluent Tee Filter present? 1-1 Yes ,2�\)o" If yes, was it cleaned? ❑ Yes ❑ No S. Observed condition of component pumped� ------------ G. S stern Purr ped By D ve Tine Mass IAA95E Mass I D31Z -—-------- Na ne Vehicle License r\lumbef 32 sor -' nler�)rlses, Inc. -- -----—---------- -------- (rnp y I'-.- /Coca where contents were disposed: Signature C)( Hauler Date j Signature of Receiving Facility(or attach facility receipt) Date 15(O(rn4.doC- 11112 Systern Purnping Record Page 1 of 1