HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 168 CAMPBELL ROAD 12/8/2025 row
nof NOrthAndOver
\ Comn-)orwveallh of Massachuselts
-Town of _ --- DEC15202
Sy terri Pumping Record
DepgrtM
Forma 4
ent
DE P has provitae>d INS form fr)r use by bcal Boards of Healkh, other forms may be u6ed, but the
info(makion fnusk be SLJbstankially khH fsar'ne as that pfovided here Before uSfng Ihis form, e,flerk wlPh your
local Board of Healih to de(ermine the form Ihey use. The ;System Purnping Record r-nust be subrnitted to
the local Bogard of Health or other approving <:,,wthori(y wllhin 14 days from -,he purnping date in
accord<)nce will-) 310 CMR 15 51 -
HOUSE: ea
A, Facility Information BUILDING front 1:)ack side rear left
DECK: under,
Important:When
(lllGig ou! fornos 1 `'>ystF'li1 ( ocatl )I'l:
on floe
ri CoIho (lf3f,use r>nly lhf7 1;�3b
kciy W move youf Rf7rir+3 s
Cursor do nu( NA
use he r e l u r n --- P � � C::�� --
C,IIy rCrwr, Sl lh lip ode
key
rySIer,ri Ownef
F4C)tfrr�Ss (�I U�PiGrn�7( from, iuc,+rtr.rn}
IMA
.....Lip e,adr
r f:�Hr7ho ne Nurrrb8r
B. Pumping Record
1 (Date of Purnpin<T _-___ .........-_._ __.. 2. Ouantity Purnped _._... _ _._.. ..... ......
G¢fllons
3 Co npcnc nt. �_j Cesspool(s) [{ ^ e ptic Cank ( ) Tigg )i Tank [ Grease Trap
] Ulhe=r (cfeuscribe)
e EffIuen( Tee FiI:er pre,s e oI? ( 7 Yeu; r) If yes, was it cleaned? Ye5 (,� 1�10
5 Observed cor'di(ion of cornp()nenl pr.arnp e;1
6 Syste r }.' e.frrrf)f c1 By
0 e line N1 as4 1AP95E M tisc 1AD311
l ;zrne Vehicle Llceose Nu ber
7 c: tlon whe(e contents were di4>pose.d.
......_. _
7igrrnlum of t-aulef )al
sIranrsturr, f:7( ewiny I aciVily Of <otlaclr (<y ili(y rr,f,e,irkt) Jule
(arrn a.CIC c 11112 5yste rn Purnpiq Recarrl f),ayr; 1 r)(