HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 70 LOST POND LANE 10/24/2025 Town n of North Andover
Comi7�onwealth of Massachusetts
, — City/Town of OCT 2 4 202
s t
yst� -n Pumpincg Record
�= Fora, 4
Health
DEP has provided this form for use by local Boards of Health, Other forms may be used, but the
Information rr'nast be substantially the sarne as that provided hare. Before using (his form, chnol<with your
local Board of Health to determine the forrn they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from -,he purnping date in
accordance with 310 D AR 15,351,
____._ . . __. _
. HOUSE front �ack „ ids . r' left (r ph
_. _... - __.------ _.,. . __. .-__ _.- ._._..__ .. _
A. Facility Informatlorl BUILDING: front back side rear left 6g t
Important: when DECK: Under
Miing ou( forms 1 System? Location
un the rompulef, ,,,
use only the (abKP
f SAC. ..
--
key(u move, you( Address _ __.
cursor-do not �,,r"� � ,� /,�,�,/f
use the re(um _ ,. _.. _._ �la� "l- MA
key. y S(a(e ,__- Zip Code
(;II f frswn
2. Systern Owner:
lek✓n2151 .. ....
Address (If differon( frorn Icrc,�(i4rn)
- ---
MA
C;Hy�rown staie
Ciro ode
7efephone kie
_._.-.._- _--_------ _._._...._...--- ._ __..___.__���..��-----
B, Pumping Record
1 Date of PurniDin --- ._ .__... 2. Quantity Purnped: -_._.._ .....__..,.....
Dale, Gallons
3 Component _3 Cesspool(s) eptic -tank ] Tight Tank ❑ Grease Trap
(� Other (describe): ___ __ _.._ _._._.__ __.___._.__ __.---____-- --.__... ._.._ ._.. __..__ . ,_.._....
4. Effluent Tee Filter present? [_] Yes [ _ e� If yes, was it cleaned? ❑ Yes No
5. Observed contrition of cornponent pumped j
6 stern !=ucriped By
Da v e 1'inc,r Mess 1AA95E M<.ss 1AD31Z
�nr Vehicle U eme; lvumtaer
E�atesrlrl .::nt�arflriss, Inc
Company
7 Locati rr where, contents were disclosed
L ,U r
_
5i r a(ur of Hauler e r D a l e
Si��nature ryf F°tEc:eiving Facility(or a(i sr,h facility rr r;eipl) L)alc
i5forrn4.dec- '11112 SysiCrn F'umpirig Record • Page 1 of i