HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 26 SHANNON LANE 4/21/2026 Town of NofthAndover
L\ Commonwealth of Massachusetts ���
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City/ down of
Syster-n Purnping Pec;orci Form 4 i tn Department
DE P has provided this form for use by local Boards of f ir�;allt�r. Other forma, n)4ay be used, but thdr,,
information must be substantially the; same as theat Provided hrre BEIfor€=; using this form, check wilt) yod.0
local Beard of Health to determine the four) they use, The Systen-i F'urnping record ))rust be submitted to
the local Board of f-fealth or other approvincl authority within 14 clays from they pumping date In
accordance with 310 CM 15,:351
H0U SE: fr�.ont gar,"k Idn rear Ir ft � at
FacilityA. infort-nation
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f�1,11Lt�' ,iC�1e rr;�id Ir,�ft rilrP7t
Importaot:when DC,C.K: tinder
fllldnra out forms 'I, Sys(em) I._cacation
on Um c.urnpu(er , " &// )
fh/tt(,, ,�"� 1
use offly the t)b
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key(o move;your AcicJmy _
cufr)or -do(1ol , ��p�r
use the f e t u r n __.�_........._,_..._._ ...... __._.-. ......- ....�-"4'' 1. G MA
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�dctrnss (If dilir;renl (ron)Ir�c;aUon)
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E�. Pumping Record
1. Date of Pumping --- ._.._ 2. C.�u antif Purr)pp
dal( y ("-Mons
3. Component: [ 0 Cesspool(s) (_-�ia "Tank ❑ right Tank r_� Grease .1.rap
C_) Other (describe): ____ ___._.__ __._---.
4 Effluent Tee Filter present? ❑ r-s.s � o If yes, was it cleaned? El Yes ( J fqo
5. Observed condition of con")ponent i-4urn 7ecj
6 S stern PUmpr_cl E3y: �
Cv-D Il ey_...----------- _- _ _... _Masi, "1P-A95E Mass 1AD317_
Y1E \/ntYl(1In 1 i(7f"n,�; Nurrrl,'7 r
�fises inc
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Cornparry
7 L ti n where contents wefe dispose,(
Sigr urea of Hsuler )aie
ign2lurr; Of Receiving aCi ify (of alttar.h �.dcilily rr,/;edpO
15forrrr4.(Joc- 11112 y le m 4=�urnl,>irw,1 f;e;rr+rc f`'raye. 1 r�r)