HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 781 WINTER STREET 11/7/2025 Town of NOrth
` Con-lrnonwealtt7 of Massachusetts Andover
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City/Town of No
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ystem P umping Rec;orc.�
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r_� > Health
DE:P has provided this form for use by local Boards of health. Other forms rrlay be LIsed, but (he
inforrrlalion rriust he subslanlially the s,-)rne �s f :.if provided here. Before using [his, form, check with your
local Board of f_iealM to de(errnine the fo rrn they use, The System Por-ripirrg Record rrlus( be submitted io
the local Board of f--ieaRh or rather appoving ault�)Ority within 14 days frorn 'he purnping da: e in
accordance witY7 310C MR 15 351 __ ---__.
back side rear lef
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A, Facility In�ornl� f
rnportant:When D CCK� unde1,
fIdI g oW torms
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B. Pumping Record
1. Date of Purnpin Ci 3ie._ _. 2. Quantity Pumped
Gallons
a C_
3 Component (_,J � esspcaod(s) [_ Se tic Ta nk � T ic3t 1 Tank r_i Grease Trap
.� Oiher (describe)
zi Effluent Tee Alter preser- t [_f 'Ye, NC7If yes was if c.lea"irrci i ( ] Yes ( ] No
`i. Observed condition (.`)f cor'n1:oner.011t.atrtl)ed
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6 Cri
n Pt,jmped By
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ire contents wc,re r1� ,J>o�srrr_f
/ l rtr swat�un where
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,rlrjr'iultrru o cr viv 1)9 t �rc.ilily (r>r rillac;h Issuility (r.t',ri t) lJutr,
5forr7�4.dOc 11112 ;3yste�rr7 Purrtpiny fc c;�rd Nage 1 of I