HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1514 SALEM STREET 5/18/2026 " r f Nofth Andover
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C1 ty/Town of
MAY 2 2 2026
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<< y Ing Record
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Department
f)EP has provided this form for use by local Bowds of Health. Other forms n-) ay be cased, but U'1E,
information must be substantially the srarlae sass tI) at provided Mere. Before; a sim Phis, forn), Cheek,,
heek, wish yc,ur
local Board of Health to determine the fotrn They use, The System Pumping Record rnust be, subFnitted to
the local Board of f--lealth or other approving �Wthoiiiy wilhin 14 days fron) the purnping date;in
accordance with 310 CMF� 15
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A. Facility Information J n aack sidc ret rriiginf t� V t
tniportant:When DECK, under
(M ru)raW forms 1 Sys tarn Location
ors 0)e Cornlautor, f
u,e only Me tab (
key fcx move your Aciclrn r s -- --
cursol -do not
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2. S stern C>wner
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Telephone tvlomber
Pumping Record
, Date Of p T,; 2. Quantity PcjnlpE d: Gallons
3. Component: ) CFastpr.>cal(s) —ptic -Tank,, I ,'f 'Tight Tank Grease T'r;ap
L.J C;tkler (describe)
4. Effluent `fee filter present? (..] �,/cs ( . lr> If yes, w<,is it Yes
5. Observed condition of r ornporror)t f>urnpetJ
6 S stern P(,fmp-d By: �
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(. ave i Intr r 3 1?_
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ea(eson CnEer prises, Inc:
7. o , (on where„contents were dispo r.(1
GLSL)
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Slgr7alure of Receiving ( acuity (or attach (ar�ilily rr:�cP'ir7P} (.)�,�c
lfforrm.doc- 11112 `yyt>Iern F'i.jrnping Record PrAw-, 1 rat a