HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1070 SALEM STREET 5/28/2026 Con-Irnonwealth of Massachusetts Town of North Andover
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System Purnping Record
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Form 4
�. Health Department
IDFP has provided thisform for useby local Boards of }iealth. Other forms r-nay be used, bW the
information must t)e substanlially the sarr ee> as that provided hers. E3afore using this form, check will) your
local Board of Health to determine the foi rn ii)ey use The Systern Purnping Record Rt(.1st be submitted to
the local Board of Heaith or other acipmvincl authority within 141 days from -he pumping date in
accordance with 310 C MR 15,351
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A. Facility Informatior7 SUILC71NG: front back sick rear left right
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B. Purnping Record
1, Date of Purn:rin4 -___...—
f g (5ale Quantity Pumped,
Gallons
1 Cornponent. (' } cesspool(s) [-.� ptic .1arik
(❑ Tight Tank ❑ Grease Trap
Other (describe):
4. Effluent Tee filter present? E.} Yes r'J n� 0 f yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of corny nent pumped
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(35. Sy ell) Pur;nped By
Da 4rrr,y Mass 1 AA95 ass 1 AC)31 1_.._ _ :µ
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