HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 41 CROSSBOW LANE 7/14/2025 (3) Comi �onw lth of Miss cr7us t s Town of North Andover
❑ _ City/Town of
S rr► P m JUL 2 1 202
} _= yste a ping Record
F o r rrl 4
Health pp r� d:
DE-�P has larovided this form) for use by local Boards of Health, Other forms 7r����U3��mul the
inforrination r-tust be substantially the sarne lhrat provided here. Before using khis form, check with your
local Board of Health to determine thav form they use, The Systern Pumping Record must be submitted to
the local Board of Health or other approving alltt-lority within 14 days from -he pumping date in
a cco rcl a nc e with 31 b CM R 15 351 -------------------
HOUSE: front ac, side e`1'` IT❑riF
A. Facility irlforfTlatiot7 6UILDING: front back sides rear left rift
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Cllyrrown Slate
Telephones Numlber
B. Purnping Record
1 Date of Pturnping _.._ _.._.._, 2. Quantity Pumpecj' ---- ---------
C)alu Gallons
3. Component: (_) C:'essp(:)ol(s) optic Tank ❑ -Might Tank ❑ Grease Trap
❑ O f h e r (d e s c,,r I b e)
4, Effluent Tee Filter present? [_j Yes (� No If yes, was it cleaned? [] Yes ❑ No
5. Observed concii(ion of c omponenl pumped:
6. Systen-t F)urnpF.d By
Dav iney __. _., _ Mass, 1AA95E: Mass '1AD31Z
NA( rs Vehicirt License Nu bPr
B fPson F nlprpr Inc.
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7 L cation where c Nerrts were disposed.
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Slgnalure ofectiwlny F aCdily (gar (&�r,ility resr;r„opt) Date
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