HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 158 FOREST STREET 10/16/2025 4 Commonwealth of Massachusetts Town ofNorthAndover
- City/Town of
System Pumping Record f° 2025
_ Farm 4
DEP has provided this form for use by local Boards of Health. Other forms A` y be'us d,-bu�th(§�d •-_A..W
information must be substantially the same 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 the pumping date in
accordance with 310 CMR 15.351. -
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HOUSE: frcint�back side rear I ft right
A. Facility Information BUILDING: fry back side rear left rr t
DECK: under
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filltlng out forms 1. Systen"1_Loca q
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use only the tab
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CityfTown State Zip Code
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s' Narne
Address(if different from location)
City(Town State
Telephone Number
B. Pumping Record
1. Date of Pumping _._._..__._-___--_—__--_. 2. Quantity Pumped: `____.________
pate Gallons
3, Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): _...__ ____._._._-----.__. --.---_-____--___
4. Effluent Tee Filter present? ❑f Yeses No If yes, was it cleaned? ❑ Yes 0 No
5, Observed condition of component pumped:
6. System Pumped By:
DaveTln�y Mass 1AA95E Mass 1AD31Z
Name - " p� Vehicle License Number
a eson Enterprises, Inc.
Cotr�pany
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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