HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 167 HAY MEADOW ROAD 5/13/2026 ti Con')ITIOnwealth of Massachusel�s Town of NoO Andover
c;=z City/Down of _--
o System Pumping m p�J i n MAY 1 2026
Y C� o�GOrC�
-pper y
F o r n_I 4
DEFT has provided this form for use by local Boards of Hea I .P h APPAOMPIA, but the
information must be substantially the sarne as that provided here. Before using [his form, check with yc
local Board of 1--ieallh to determine they foirn They use. 'rhe System f'uniping Record must be submitted
the local Board of Health or other approving aulhority within 14 days from .he pumping date in
accordance with 310 C M R 15.351,
-- __-- -- __ NOUS front pack side real 1f>ft
-
A, Facility Information au(t.DING; back side rear e
important:Whcin
(7[CK: (Inder
(tiling oul imms 1. `J'ystern Locallon
on the cornpuler, p
use only U,e (ab 3A0 7
Kuy to move yo,m A00 s
cursor -do CIO( '0A
''
key. C;Ily�f-own sia(e. 7I1)code
- 2, ay�(etn 0 V
1er
i
---- addrass eIf diri(,rei+nl from Ioc,F�llc�n)
MA
Zip Cade
Telephone Number
B Purr inch Record
1. Dale of Pur-n pina o Ualc Quanlity Pumped
-- -
Gallons
3. Cori pcnc.r,t o-1 Cesspoolm 4 ic.Tank ❑ Tight -Tank g (_� Grease -f ral>
4. Effluent Tee Filter present? ❑ Yes "o If yes, was k clea,�ed? ❑ Yes No
5_ Obseived condjh0r( of cornponenl cramped:
6. System Pf.trnped By:
Dave I e Mass1Z
------ ln_ __------ Mass--------'lAA9SE---...--------- 1AD3
-
Name vehicle License Number
B- sore Fnlerprises, Inc.
C c>(rl(Jdny
canon wile (e co enr > vverc dlspot3(d
C
-_.
sic nature or ftiE c.clvl�,r f srcilll a t�Uar h (acilil recei>t - —
� ) Y( 1 f ) (pa(e --
5for �4.doc 1'1112 Syslem r'(_(rnpiog itecerCf Page 1 0