HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 44 LACONIA CIRCLE 11/14/2025 Con-m-ionw�ealth of Massachusetts Town of N011 Andover
.: U t y/w�_c�w r� of NOV 202
Systei Purnping Record
n
Form 4Health
DE F-1 has provided Chis form for use by local Bowes of Health, Other forrr75 n'tay be used, but the
rnforrl7afion rrrgJst be sutasfanhally the s rne as fhaat provided here_ Before cfsing This fora, check with your
local Board of Health to determine the fora-i (hey use. The Systen-a Purnpirig Record must be submitted to
the local Board of Health of, other af)poving caulr-lority within 14 days frorn the pt,trnpincl da- to in
accords arise with 310 DAR 15 351.
_.._ HOUSE front Hato �sicle rer. (raft rl ,
A. Facility Infori-natiol BUILDING: front back side rear left riga,rt
Important:v bon DECK: und(2r
Illllncg out (orals 1 Sy`rslc I11 Location
on the Cornputef,
use of fly Oho late
kr7y to move your llrJrlro ^,
c,.rrsor do not MA
Use Me fetuff) ....._. .-.-_ ..._ ... , -- .._... . _._,... __.............. _,
key c;uyrroWr, r�<,te zIn r,,oa�;
f 2. 3 ern C:)wner
�
Horn
Aodfoss (it UiifCtont from Iocallon)
MA
CllyrroWr, _ State --
z r,>Co
fr„le bony hJurr'ik,7er
B, Pumping Record
1 Date of Pt_arnpinc. _ ...__._-. 2 C uarrt t Pt.art1 aeca -.��.1 _...,._..
C7,Ify Y ( C`IIGfi
3. Cornponent Csesspr,:,r-A(s) [��,,`,rfef>tic: larik 0 Grease
ri r,I rink ��r�-,_ we L.rral:,
(. (7 l h e r (describe) g�'������
4 FE.ffluent r:7 ee F c( preserti? (._.) Ye,s [_"I No If yes, was, it dea,red? ❑ Yes
5. Observed condition of ccornpone nl I-,)urnped:
61 CSys, n tt,roped Byrinc y Masss �tA.A€5E:= Mass 1 AD31 Z --Vehicle Licen (,� Numbe
n E=n[erprises, fnc;.
ny
-- -
LocaPion where contents were disposed
Cal LaU
Signatwo of hauler U to
",lcansrtury of t�( «ivinr� F ncility (or attarir I;ictlity a>(,�>,i1>[) (Ja1P �--
`afCarm4.dUC 111t2 SyslernPunnpirlg -Zt;Corc.f cage 1 c>(t