HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 35 TIFFANY LANE 8/15/2025 I own of North Andover
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'i 1 ON PyrFown of AUG 2 5 2025
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SySter ��> rn �� ir7g
Form a Health Department
(CEP has prover ed Ws Pam [m tmp by for rl f;nrr d, of f fC'H, t)lIYC"( forrns niny ear t ,c>ci 0 th("
inforrnntfor) rnu f bce trh slaanh,.,Ny [he same as u al far<)vieft d We H3r fare trying Ihi , frvr-n chr�rk rwi(f) yoi.j(
local Board of HeW 0 de termle Me lwm mey use Ale SyS(t_rn E=1.ImYng 4a;ewct RVISf ht!',>UC1(iUCIE;;°C) Icy
Me local Bowl of He Hh or olher approving r,Iuthol ly wilhin 14 days from Me pumping dMe if)
accordance with 310 CMR 15.351,
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A. Facility Inforr-mail 1 RUILDINC-� (marry bFtCk SidC rQar I01 rlf,,ht
rnpomant: When CHECK undm.
(I mg uu( forms 1, Systa71 I_ocalion'.
on cornpuIef,
um only Me lab _ 4
kr3y(o move yuuo A<i<arr ss 7
rse the return �.._.._._S_.__ (�f'a.L _ _ ___-.. __.__ M� .----- 5��� Y
cik TI'owrr t�' ----_. ---.__.
key. y SIaIv' Zip code
2. Systq In Owner.
Address (If differnot from} localion)
MA
";I(ytlowr7 7lalr rip Code
Ieplc;phnrlo PJurrrf,rf7r
�lrnPln9 f�ecorci
1. C)a(e of Purnpin C7aaaie _.... 2 Qu2nthy f7u mpect oak .___ . _....
orrs
3, Component � � CeshpOOI(s) Septic T�ank� (� 7 ic3h1 Tank Crease fraf:,
Other (describe) _ _.
4. EKWen( Tee Filter present'% ( ) Yes, C :_ IVo If ye:;, was it c Ieaned (_. ) Yes fvo
5. Observed conditw) of e ore ponent t,n-pul:
F>. Systo t F7t,.yirrtperad By:
Dave They. .__ M�a s 'IAA95E_ Ma s 1fa031Z
Nome /` V/r,�hlrir, I icrry;ra Wunber �
kpmn n(�r iin� Iris
cr>r„r7ar�y
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Slgnalur n( ti rllel Limy,
Shtnalure of Fsecr3lvfnc) cillty Co-, atiae,tr f;,cillI
l5(Orffl4.dQC' 1111"1. S�,rsle?m(.>tirt,tninn G,��„„i r7.,._ _, .