HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 312 FOSTER STREET 5/13/2026 OWn of North Andover
CorTm-ioriwealth of Massachusetts
City/gown of MAY 5 226
System Pun In Rc.,cor'c�
7 Health 9
DEP has provided this form for by local Boards of Heallh. Other forrns may be used, but the
informalion rnust be r,l..,k skanli<1 Ily the Safne, as fha( provided h.erc,. Before using this form, check with yt;
focal Board of Health to deg te rrnine the foray they rase. The Syslern Pumping Re,coid roust be submitted
the local Board of Health of oltrer afsproving authority within 14 days frorn -,he pumping date in
accordance with 3�10 CAMR 15,351
Facility t ark sidF r r,r
}IC�US left.
_,C: ror�t
A, � nforniatiol'1 BUILDING-, � �t° back side rear lef7
Iml7urtanL Whtm
D1�C:K: rtr;:{er
filling out (owns 1 Syslern I_(:cation
on the ct)rnpuler,
use only 01E (akr .!()_)(I, _&.�'(..
koy to move your A00rress _ _ --_-
Cufsol �do nol A)
' U
use the reluto _._
key- 'hyru"''' �rtee Illy Code
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g,�aY PJ�rnrs
Addroes (1( CfiYfc,rtpiwl born IocaUcyn)
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City "c>H✓r ,late ?if)Cod
a
Ye,IePhone hlerrbat
B, Pumping Record
1 Oate of r'unIpinca �_s -- 2 OuantiPy Pumped
�� Icirts
tir,.Tank [ T igr)t T a n k ( .� GfPasE Trap
h] Olh(. r (rlescflf)rwo) —_
4. fflts rrt ie��uilir,,r ,sr�nt"? C._� ye ��..
t.
If yes, was It c.lea,)ed? C Yeas _} No
;,i Observed cC7rtdilic)n of corn onernt purnpe('I
System Piirrrpf d By.
f_)a v E T I n e.y Mass`� t f-�A9 5 E Mass 1 A 0 3 1 f
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Na(r)E"
7 I_csczihon whef e c;crtrlcnl,r «r,>rr; c)I spo ,rid.
C)rtadr,rrr� c7( 1 i-atsiGr _..._ ... .._.
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41tnalurr" of lit.<,e{vinc F<rcldil� ur ;3ti,tr,1� I,.�r;llih r+�c,(;t)dDate
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Sys k2ln Pumping R7f Cord ('age; 1 c