HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 536 FOREST STREET 4/27/2026 Town of NofthAndover
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s System Putr drig Rerorci
DepartMent
Form
DEP has provided this forrn for use by local Boards of f-jcakh. Other forms may be; used, but thEr
inforrnGation must be substantially thy: S,a ne as that provided here. Before using phis foern, chnch with yr,of
local Board of Health to determine the (orn') they use They Systern Purnping Record rnust b(, s(.11arrnitted to
the accordance Board
of 1H C,"ithor 15,351,a.r K)viraf} authority within 1 e4 days from the pumping date;in
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E>lJ4,f front 7�iCk CIr rc;ar Ir>f f11�t_ .
A. Facility Information E3t_1I1.Dr NC.7 front hack side, real Ieft r'ip")1
mpor#an(;whcn Df"CK, ender
(Ming out fe'rrrns Sys ern L-o atir_)n
kvnlht; rrxrn,el(or,
tit only ttin lint) -`L 9
kr,y Ica rrxwe your ll r�
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cutout dO not �( fVIA
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Ykr,>_y .,ily(1'e'Swr7 Slate ;'tr>l:ot,1c;
n l 2. stem Owner
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Adc4rcivs (i((jil�fryn,nl from Irx;allon)
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Catyrrown _._ si E 7_04q
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rC7r10 Nurnbl�r
B. Pumping Record
Date of Pur7aping jlrA.__._._ _ _ 2. Quantity Pumped _
Gallons
3. r-
Com>one
( ED Cesspool(s) 4>tic rank Tight Tiyh f
� �� C.ira�„tsE> 1'ra�
E1 Other (descrif)e) _ _._.......
<1. Effluent Tee Filter present? O 1'cr.> r;, E yes, was it cleaned? �.] 'Ye, ( J No
5. Observed condition of co(riponen( f� lrnfce��m,�
5 S y:a l reCV r I Ijrqpeci BY
0aveTI rle,y - Ma s s 1AA95 Mass 1AD317
(� (11f vt,trltJe^ I_If C(oL t� ilrrllt,r
E3akr�s ern ��s Irlc
Corntmoy
7. Location wtleff Contents were disp(:J.`c"O
ynniuro of Haulor
ait�n<+Itlre ofFter.;f Receiving F-af.11if}I (or afdacY�l (,rr,i9i(y !F°cr�ipl) t�r�iry _
15forrn4,doc• 1 M2 C;wystef'r)Pumping Record . l:'rrel 1 of r