HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 82 LIBERTY STREET 3/26/2026 • Town of Nofth
Andover
CommonwealthQ of Massachusetts.'�_ MAR 3 0 2026
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System
PumpingRecord
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Health.Department
DEP has provrded Y r °. ..
this form for use by local Boards of H
information must be substantially Health. Other forms m .
bstantially the same as that ro�i •may be,uSe►�, but the
local Board of Health to determine theded here. Before using this fo
the local Board of form they use.The System f'urn � �� check with your
Health or other approving authorityping Record must be submitted to
accordance with 310 CMR 15-3 within 14 days from the Pumping •
��. p p g date in
A. Facility Inf
artnatron
#mpoftnt:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address `
cursor-do not _ L
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key. CitylTown
2. "Na�m .
Mate Zip Code
er:
Address(if different from location
Clh►Town
- 4
4 .• }' - ' Y ' state _ •• .. ., , i
•,.- "` Telephone Number
MPUtnping Record
7. Date of Pumping _
Date 2. Quantity lumped-3.
Component: El p°D{SS S} Septic Galrons
� 1"ank
• � light Tank El Grease Trap
Other(describe): •
4. Effluent Tee filter present? [] -
Yes El No if
Yes, was it cleaned? Yes No
5• Observed condition 3 k �7 Qxponent pumped t
6. Sys ern Pumped By:
N e
� � r
r
Ury_
vehicle License Number
r
Company
7. Location where contents we .
re disposed:
L
Sign of Hauler
Date
signature of Receiving Facility(or attach faciii rem* R
Ptj Date
5 OMAdoc-11/12
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System pumping Record•Rage 1 of 9
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