HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 101 DUNCAN DRIVE 11/14/2025 Commonwealth of Massachusetts Town of NOrth AndoVer
City/Town of
NOV 14 2025
System Pumping Record
Fort-F)
Health DePartrneq
CLEF' has provided this form for use by local Boards of Health. Other forms may be used, but t)
information must be substantially lhe same, as that provided here. Before Using this form, check with your
local Board of Health to determine the form they use. The System Purnping Record must be submitted to
the local Board of Health or other approving authority within 14 days from she pumping date in
accordance with 310 CMR 15,351,
HOUSE: Qro.'ntback side rear left C11 !:
A. Facility information BUILDING: front back side rear left righ
Important, Whorf DECK: under
filling OL11 fOfMS 1, System Location:
De
the cornputef,
use Only Oi ta rt b
key to move yQLJf Address
cursor -CIO oot MA
use the fe(tim
key. cilyfTo-r) state Zip Cade
04 2, System Owner:
v
a me
Address (if different (turn tocalion)
MP cllyrroWn slate
— Zlp Code
Telephone t4_1_rnbe(
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B, Pumping Record
1, Date of Pumping (jai2. Quantity Pumped:
Gallons
3 cornponent: El Cesspooi(s) Septic Tank E-1 Tight Tank ❑ Grease Trap
Other (describe),
4. Effluent Tee Filter present? 0 Yes )o If yes, was it cleaned? ❑ Yes No
5. Observed condition of con-iponent punnpe()
Y (e iefyi"i Pum
ped
6 Sy By
_D_ v e Ti n e,y Mass I AA95E Mass I AD3iz
Vehicle l_Iconse Numb
BaIeson Enter rises, Inc.
coo parry
7. L fc, i(ion where contents were disposed:
,L,3 $—'—___ __ _- _
------------
)iqnatufe of Hauler Date
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Signature, of Receiv ng F acility (of f,ciij y
e,C eto Date
15fo(ni4,doc, 11/12
)Ysterri Pumping Record i)ag(,, 1 of 1