HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 TIFFANY LANE 4/27/2026 O n of North Andover
Commonwealth of Massachus. etts
C'ty/Town of 202
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Sys ern Purnping Record
n, f=o r rr' 4
Hee I'd Deportment
[EF) h�os provideci this forr'n for use, by lor:gal Boards of Health, other- forms may be used, but the
information must be substantivally tl`te sarne as that provided here. Before using [his form, check with your
local Board of He9,af(h to determine the form they use. -fhe System Purnping Record roust be subr'nitted to
the local Board of Health or other r�pproviog rwthonty within 14 days from the pumping elate in
accordance with 310 C'MR 1,5 ;i,`r1 _- __.
_.."._ _...__. I iO USI 7rr(C5),r)1f,
t t)� 1l
side rear Inf
A Facility inforr,iation BUH.C)IPJC: back side rear le.,fa
fmE)r7rtartt Wfrert
f:1_;K: under
(ding raft(founs 1 pry°stC m I_or 1tic.Y,(1:
u(s('w r trr�t ipulb �
key to rnove; your Addro5s
cursor -de rrc>I
use Olerr?U,urt
key. Clty rawer „IFrte Z„p code
r { 2 Systenj C7, rner,
WIA
/J r�ci tTk'
Add(oss (H different from Iracation) "
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r;tty(lrrvVrr
fi�l�;fa t---- t�urnk7ear ,.
B. Purnping Record
1 Date of Pumping ate 2. Quantity Purnpr d.
G@Ilon.s
3 Cor-riponent r: cesspool((
) Trara4< i.iyl7t Tank ).� (,,re ise; 1'r<7(n
(w J Other (describe).
4. Effluent Tee Filter present? (_�j Yes Z Plc,) (f yc-,s, was it cleaned? F- Yes
fetes
5. observed of c ornpor :r(-t un,)E,red,
(�. sten'I r'Ufn )e;ri Lay
(have ` Irie Mras��s ' AA95E ,s 1AC7317_
_. _.
Lu'pe Vehicle I ,.u,-nse, Nmnf'7C.r
Bateson E nlerpreses in<:
7. t_C)(, aj.car vvfle, contents d1sf)os:, d.
gn< ff{� _
�i�,{n�11wa, �(r@t.r�.;tvinc� f �ac.if(ty (of 71CraaMt fsr�;tlrfy rr;c,F�i1)1) L`Y+tr;
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