HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 112 COLONIAL AVENUE 10/29/2025 Town of North Andover
Commonwealth of Massachusetts
c City/Town of OCT 31 2025
Pumping
System S y p ng Record
Forma Health Depertme
nt
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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 roust be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 319 CMR 15.351 ---_. ._
HOUSE: rant hack side read efts right
A. Facility information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your ddjess
cursor-do not /!"I�t MA 1 ; ___.___...
use the return ___.. _.._ ._ _.___-._—.�_ _....._. .. ._ .__._._..._... __ _.�._---__ —
Key,
City/Town State Zip Code
2. System Owner:
_ ____ _
Name
NYR �`�
Address (if different from location)
MA
._.._ -- ___-__.__._.__._ ___ .___.._. .__.____._.. ........ ..._._._
City/Town State r, Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping —A� - 2 Quantity Pumped.
Date Gallons
3, Component: Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (descrlbe):
4. Effluent Tee Filter present? ❑ Yes ] No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
& System Pumped By:
Name —...__. Vehicle. Nurnb" MASS 1AD31 )DaveTlney.__ Mass 1AA95E
_Bates_on Enterprises, inc.
Company
7. -Pion ion where contents were disposed:
CS
A),
Signature of Hauler Date
Signature of Receiving haality(or attach facility receipt) Date
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