HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 311 DALE STREET 11/14/2025 Town of North Andover
Commonwealth of Massachusetts
'Ct /Town of
EN
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stem Pum cord
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DEP hr�is provided this form fof use L)y local Boards of Health, Other forrns rrlay be used, but the
inforr-nation must be substanh ally the s,-wie as that provided here. Before, using this fr ri-n, check with your
local Board of Health to deternnine fficf foun they use. The Sys(ern Purnping Record must be submitted to
the Local Board of Health or other ad:)pnoving authority within 14 days from -he purnping date in
accordance with 310 C'MR 15 ',51 -_—_.-
HOUSE: frpj,� back side rear left
A. Facility Information SUILDING, front back side rear feft rite
Important: When
DECK: under
filling out forms 1 ?ystern location:
uythe computer,Ia o 1 _
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key to move your Addro s _.
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use lire re(utu vY
keycflyl-l"own date ZIP code
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Address (if rdi(te(onl fron—) locattoin)
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C;llyl'7"<>wn �31a(n Ip Godc
Ta ephorie Number
..... , ___.. ... __.._..- .--- ..__ _,.._._.-_.__.._..._._-_ .- ------ __...____-. _ .—_------_..__.._-_._
B. Pumping Record
1. Date of Pumping _--- --..._-.._. ...-..__.. 2. Quantity Purnped'. �
Uale Gallons
3 Cor-nponenP. C-3 Cesspool(s) °'Septic Tank [] Tight Tank F Grease Trap
0(her (describe). __.____,__.. _-- ---------- ---..... _..____-._____..._.. .. _.
n. Effluent Tee Filer present? [_.? Yes [�Pd'o If yes, was it cleaned? Ej Yes [_] tVo
5 Observed condi(ion of component pumped
6 Sy; en-a Pumped By
D vc Tine __- Mass 1,�A95E Mass 1AD31Z
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E af4nrl E 17t �rE�rl�f�.� Inc
t;orrrr><sny
f c tti n wf (efits wt,ry
Wit:) '
Signatme of Hauler
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_..
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lyirr Lure of Fie c iv acilily(7r tirsw:}) (rrcilily re„rroryl) Date
5fo(m4.doc 11/1" ,,deer Pl.rrrTim) Record - Page 1 of t