HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 33 CRICKET LANE 4/29/2026 Town of
North Andover
Commonweaitt'� of Massachusetts
C4/-1 own of MAY 1,3 2026
yst rn PurnpIng Pecorci "
F -cy form 4 � .�,� ���� Department
DEP has provided this forrn for use by local (:30sards of Health, Other forms may be used, but thery
information must be substantially the sarne as that provided here. Before using this form, check with yow
local Board of Health to determine the foun They use. l-he System Purnpind Record must be submitted to
the local Board of I-leaith or other approving authority wkhlin 16 days from the pumping date,in
accordance with 310 CMR '15.351
H(")US E front Etc sine rear figh l
A. Facility Intori-nation BtJlt_DIn1G front hick side rear Ieft
mportanC wtmr) DECK: under
filling out forms 1. System Location,
on use o corr7puler, ,.
�.f5e
only thca lab
keiy to r"nova yarn Address
co(sor do aryl MAyr,y ily own Sate 7,ip Carle
e
2. Syste(rl Owr"1->r
r Ni --------
-= _ -------- ------ - -
c _rc�3s-(i Clili�°r--rsnl (turn locatio-n) -----
MR
ity(1'own Codc:
Telephone. Number
B. Pumping Record
1. Date of Pumping ��1e= -- —- 2. Quantity Pumped - ----.-----._..
Gallons _
3. Component: [_) C esapool(:;) Sr., tic, Jank ).LL] Tight Tank [_] Grease Trnp
L__] Clher (describe) — -- ----___
4. Effluent Tee filter present? Yes ���.. f yes, was it cleaned? (__] Yes iD t\Ja
a. Observed condition of corrlpoor^ref p ec)
System Plamf ed Ry
(Dave 1IncY _._.- Mass 1AA95F Mass IAD31I_
__.__._ _--_.-_-- _-_..
Nary c; _._. - --
vehlola Genae rW(fmf er
f3atr�s•�.aa�L:�1�'Prises Inc.
Comp<)ny
j LOCaII(7(I Wr1D(e cofI were UISpUSS0;
('LS0
SI rlaluro of Haulor - - —
-_
Signalclre of Receiving f=aality (or allarh receipt) C>al<r
15forrn4,doc- 11f12 �,ysl�rrpurnt)inq Rergrd f�s�Gtt 1 rlf 1