HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 112 STONECLEAVE ROAD 3/12/2026 �.
=a.�.�. Commonwealth of Massachusetts Town of North Andover
City/Town of 22
v_ v° System Pumping Record
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Farm 4
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DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use, The system Pumping Record must be submitted to
the local Board of Health or other approving authority within '14 days from the pumping date In
accordance with 310 CMR 15,351,
HCUSE: front cj<_ side rear lefrt righr
A. Facility Information BUILDING: front back side rear left right
Important:UUf1Pn
DECK: under
fllltng out forms 1, System location.
on the computer, d
use only the tab
key to move your Addren
cursor-do not s
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use the. return
Key.
Cityffown ,'-".,fate Zip Code
2. System Owner:
I�
___
r\� Name
/tlu"n i r�'fJ
Address (if different from location)
MA
City[Town
State Zip Code
- ----- ---
---
Telephone Number
B. Pumping Record
3�� �✓ 1
1. Date of Pumping _--- _.. __._._._.._-- 2. Quantity Purnped: _-__
Date. Gallons
3. Component: [�) Cesspool(s) Septic Tank ❑ Tight Tank [I Grease Trap
[� Other (describe),
4. Effluent Tee Filter present? C Yes [ No If yes, was it cleaned? C Yes (_a No
5. Observed condition of con-iponent pumped:
6. System Pumped By:
__. _._._ t S
Name Vehlclt i1i esge Number ass 1 P C717
Bateson Enterprises, Inc
Company _
7, L — tion where contents were disposed:
GLSD
61gn ut5 Hauler Date
Signature; of fveceiving"Facility (or attach facility receipt) Chat,
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