HomeMy WebLinkAboutTripoli Grease Trap - Septic Pumping Slip - 542 TURNPIKE STREET 5/4/2026 Town of N00h Andover
Commonwealth of Massachusetts
City/Town of n tive MAY 2026
ystem Pumping cord
DEP has pr OVi ded this form for use by local BOIRNS of Health.Other forms may be LI but the
local information must be substantially the Same as that provided here. Before using this foam, check with your
Boardof Health to determine the farm they use.The System Pumping rd must be submitted to
the local Board of Health or other app Wng authority within 14 dlaya from the Pumping delta in
with 31 p cm)R 16.351.
A. Facility Infalrmation
h4wiI Mon
Oft Out r I. item Location:
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.Owner: ,
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�" r� �+�► �y/�/ryy, /� TetephCne Numfrer
El. L umpi Rg RecorM
1. Date of Pumping 2. Quantity Pumped:
Fete dii4tona
3. Component ElCesspool(s) Q Septic Tank 0 Tight Tank [, Grease Trap
❑ Other(d lbe):
4. Effluent Tee filter p ? 0 Yes No if yea,was it cleaned? Cj Yeas [j No
S. O erd condition of component pumped:
61. System Pumped By:
vehidm I. ranee Number
7. Location where contents were disposed:
R4 -�4
,or
lure of KeDS rng F80111ty(or ettecb fealty " Date
d4C•11f12
Syetem Pumping RemM•Page 1 of 1