HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 52 BANNAN DRIVE 6/24/2025 �5` Commonwealth of Massachusetts down � North Andover
City/Town of
System Pur~nping Record
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Farm 4
Heafth Department
DEP�nfarrnats p r�u,,>t be.provided this
form
for
u e by local 13r.rr� d ea
of Health Other fotrr)s m,-)y I)c, (jserl, 1)ul Ihc
/ s lr at provided here. Refo re using this form chec4< with your
local Board of Health to determine thr" foi rn Mey uv(t. The. System Purnping Renard must be sul.)(n tied (o
accordance lorcialn Board Health
C MRr1 h1a approving auIhotity within 14 days from the pun)ping date to
otherf ( J
HOUSE: frrn back side real eft right
A. Facility information BUILDING: front: back sicle rear left ngt-o
Important: When DECK: t_tndPr
filling out forms 1. Systern Location
of)the cornpuler,
use only fhe tab /I
<r=,y to move your Address
cursor-do not r
I.Ise the return L1L!. !" @JtF
key, City/Town ;ale To Code
2. Systern Ownerr
I;( N2rfle
Address (if differonl from location)
MA
-----------------
Clly/Town ,Itsir, Zip Cod c
Telephone Number
B. Pumping Record
1. Date of Pumping 2 Cuar)tity Pumped
C7a1e Gallons
3. Component: Cesspool(s) Sephc Tank Tar)k Tight
g ❑ Grsase Trap
C_j other (describe); ._.
4, Effluent Tee Filter present? (.__) `res ._] I"10 If yes, was it cleaned? (__7 Yes [] No
5, Observed condition of cornponent urriped,
G. Systern Ptjmped Ry
CJave T'Iney ass 1AA9 � Mass 1AU31Z
hl�rmr:�t - _ 5t. f�J�rrr7t�a�,r
OAhGgnn Enk v- rin_s, Inr.
coolfmny
7, canon where contents were di5po3cd
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Signature of Hauler Urtir --_--
Signature of fyecelving f=)ditty (or attach faclb(y rr ipl) C A; e __..
I5forrM.doc' 11/12 System Purnping record f>aqe 7 of 1