HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1175 TURNPIKE STREET 11/14/2025 Town of NofthAndover
C,omirionwealvr of Mass,achuselts
C i t y/Town of _ NOW 14 2025
System Pura yin . Record
Y � �
Forrr, Health Department
DEP has provided this form for use by local Boards of Health, Other forrns rr�lay be used, but the
ir)forrr7ation rrlL.rSt be substantially the s>imp as that provided bere. Refore using Ihis form, check with your
local Board of Health to deterrnlne the form Mey case. The System Porrlpirlg Record must be submitted to
the local Board of Health or other approving ac.rlhorily within 14 days frorn .he purnping dale in
accordance with 3110 C MR 15,351,
---- - - -. . . - --------- Ft0I.J$C fr .. h.><7r,;k >ide rear Ie rinhri r 7n knack sid rear I(f
A. Facility Information 8f-)ILDING t ft rigr,l
lrnportent:VVhelre
C7FC K, and er
ruling out forms 1 y `Ir rn Location.
useo lythe uler'
use only I the� 1 a b ��*,I', . ..-----
key to move,your Ad0ro
cursor clonald,
use Ihc: return -
key Gllyrf'own state Zip Code
2. y s t e m Owner.
Narrre
— �— Ac}dross (if oifrefool f(r„ern Iocation)
- ----..._
MA
owf) State, Llp rgcfe
TelepYrane PJur'nf7eir
B, Pumping Record
[
Date of F7�lrnplr'ca 2 Quantity Pumped _..__ �...,..._..
DateGallons
3 C c)rn)orient. ess rc,701 s
r _.._ G� " f� ) _~�""`�ur>tic �Cank (.._] ric3rri Tank (--) Grease frap
(.._.1 Other (describe)
"fVc) If y/es, was it cleaned? [�} Yes
Ef"fluent Tee Filter present'? r(..._„ ` s
`> Observed condition of cornponent pumped:
_ ._..........,_._.,.,.._--._
(3, S stein Pumped lay
1-V .( Ir Mass; 1AA 5E Mass 1! ( 3'1f'
Vehicle License N�,lrrr E,r
Balesc)r) Enter prises 1( rC _
Company
7 l atiorl er cantenls we(e disposed:
ignalum of Hauler 1) lc _. .
>I r'ralurr� U kr.c,+;riv n f E7c:rlii or .oli�rcis (r+cilik rr±ersi Op
9 g Y ( Y 6 ) C)rtr�
(51o(rN doc, 11112, System Purnpifil Reco(d R,3 , 1 f7(1