Loading...
HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 91 JOHNNY CAKE STREET 7/1/2025 Commonwealth of Massachusetts Town of North Andover City/Town of JUL 8 2025 System Pumping Record Form 4 Health Department DEP has provided this form for use by local Boards of Health. Other forms may be used, but the nformation must be substanfially the same is that provided here. Before using this form, check with your local Board of Health to determine the form (hey use. The System Pumping Record must be submitted (o (he local Board of Health or other approving authority within 14 days from 'he purnping date in accordance with 310 C M R 15.351, —--------- NG; ront 61A, Facility Informatioti BUILDIN � -back side rear left ri, Important:When DECK: under filling out forms I S Stern LocEltion on the cornpular, use only the tab 4S key to move yout Add ©s Cursor -do not MA use the return key. Cllyf State Zip Code 2 S y s tern Owner Ili I Narne morn Address (If different from locallon) MA --''02, Telephone Number ---------------- B. Purnping Record 1 Date of Pumping 2. Quantity Pumped: 3. Component. ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap Other (describe). 4. Effluent Tee Filter present? Yes No If yes, was it cleaned? 0 Yes [] No 5. Observed condition of cornponeni )urnped. 6. y -�)urnped By ave S S-1 Ba arse terprises, Inc. Vehicle� License r\�umbef ---------- Company 7, Location where contents were disposed: Signature of Mauler Dale -------------- ---------- ------- ---------- ------ ((,)r atlach facility receipt) Data ------ 15lorn74.doc, 11112 Sys(ern Pumping Record Page 1 of 1