HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1907 SALEM STREET 4/24/2026 x C ommonwe - c
etts Of North Andover
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System Purnpic7 � F��c c�rc �' 0 2026
Form A
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DEP has provided this form for use by local Boards of Health. Other forma may�a � i, ( llt
inforrnatlon must be substantially the same as thsat provided here. Before using this form, check with your
local Board of Health to determine the forrn They use. The System Pumping Record must be suiamitterl to
the local Board of Health or other approving autrtorify within '14 days from the pumping date In
accordance with 310 CMR 15,351 --..-__-- _ __-- --
front M
A. Facility Inforr7� t.'.c�t� -_._ _ �3Or rY rcr)r I e h r
y 3UIL NG front back side ieai Icft rigr)i
Gnportant: when DECK: under,
flllIng out Item<; 1. S StP ) f on the compu(er,U;e Only the 1f)bhkey to move yourndtimss 64'-
ur,or -do ool MA
use the return --...— --- — --- A-0
_ - - -._. __ __.._.._ - — — - -- -- -- —
___
Key, ily�town S�alr�' Zip Code
2. System-) Owner
Address (if different rrGrn It:>calion)
Sl _ -- --
1elep)one Nurnbr=r
B. Pumping Record
'I. Date of Pumping __
p 9 Dale --- -- - .-___-- 2. Quantity Pumped'.
C,alions — ---- —
3. Cornponer,t [_) C esupool(s) _ ef� , -rank L--] tight Tank [' Grease Trap
❑ Other (describe). -_.___. . .- .__ ____-.
A. Effluent Tee Filter present? �No If yes, was it Gleaned J" fVo
5. Observed condition of corny ne t purnpe 1
6 System) P(Amped By:
Dave -I-In - - , c " _
-------- -y--- -- - -._ _. _-_ Maps s- il�h,3�� Mass 1/�D 3'l T_
Name
Vet7lcie Li(,t r7s e lurnbf r
teson E-nterprlses Inc.
('ornri,�r73'
1. _ Cior� where contents wcrr:; dispGset'J:
GLSD
Signaiuro of Hauler Dale -------- - - ---- -----.__._._-
_______-.—_-._ _
Signature of f�ccc,iving r�acdrty (or r3lUrch facility rr++ceipi) Ualc — — --
l5forrrikdoc, 1'1112 Syslern Pumping R(rorrd • p<�,oe 1 of t