HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 296 RALEIGH TAVERN LANE 6/25/2025 Town of North Andover
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City/Town of
System Pumping
µ = ys ping Record health
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DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the sar-ne as that provided here, Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from -.he pumping date in
accordance with 310 C M R 1 5.3 51 --_-_-__ ._------- ---
HOUSE front ack �s'i`de rear left6
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A. Facility Information BUILDING: .".front back sine rear left rif
Ir7iportant:When
DECK: under
oiling out forms 1. System Location.
on the. cornputer, ( (\ f
use only I h e tab --
key to move your dr ss
_ G _..- - —__ ._- MA-- ---_ — ----- =
cursor -do no(
use the reluin cityrrown SI TS" Zip Code ------
key.
2 System Owner.
_ _ �� -- -_ _ ----- ------- __ ___------------- - -----
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lelrv0
Address (If different f(orn location)
MA
C11y( own Slalc Up Code
Telephone Number
B, Pumping Record
1. Date of Pumping _ _ --_...----. 2. Quantity Pumped G/Iton�----
Date s
3. Cornponent: ❑ Cesspool(s) 211Septic -Tank ❑ Tight Tank ❑ Grease Trap
O i h e r (describe): - - - _ — ------- _.__.--- -- ------------ —
4. Effluent Tee Filter present? y-`Yes (-] No If yes, was it cleaned? � es ❑ No
5. Observed condition of cone{ nenl pumped:
� C/ � `
6. Sys v-rri Pumped By:
avc 11nr Mass 1AA9SE ass 1AD31Z'
Name Vehicle license Number
32leso.n Enterprises, Inc.
otntiany
7 Location where cc tents were disposed
Signature o f-lauler Date
Slgrralure of Fteceivlird Facility (or <rt a&r facjlily receipt) (Dale
5(orrn4.doc 11f12 Systern Pumping Rerord • Page 1 of i