HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 162 HAY MEADOW ROAD 6/4/2026 ��;c)r�,mar,we Iti'7 Ma s �chu �tt s TOM Of North Andover
Y '
C;Fty/ 1 oVV of
N 20
26System ur "1P g Record
f-o r rn 4
Healtil
f7F-f-' has provided khir, forma for i.ase, try {rDc71 (sc,slr,i. r�( I-it,'alth forr7'as may be usr�., )ul 7r^
inforrmtion must I',)e substamiahy tt)e yarn: taf,, thral pmvidf=;r,,i Br;forc^ using this forn'i, checkwOh( yow
loCal Board of L�f <all,rr to rit;t�rrrrinc� PhC f0f_( ) They i s �Tfar��, >y.�Er�;r7�� F urnping Record must huh .<.ihrnitlr:d Ir.,>
the local Board of Heatalth or ottje( 2ppr0virat:l 3UIhO6lY Vvi(hir) '1�1 days frorra the° pumping dater In
accordance witty :310 C W` 1 S 351 _ _. .. „n
fi") Jy>E: frCant n iO irie rrr;ar p?ht
A. Facility information _ Rt1ILDIn1C: front
back ride e<-+i
Important: When DEC.I(. nCaeer
fllli(eg mjP fwrnr 1. Systern (.oc'rItli):":
on
w the
r�JG
^only IY'art (£a) tT'��C ��
-.- _ay to move yc2ur F�ciclr � _.--
cm or -do nol
use the f e(w o .._._ .�.. _._...
_.. _..-_.... _ _..t.`r
y,f? (ilyFt'owra `.a1,4Ie ....
Y Zip Code
2, Systern Owner:
frri7f.'
Adclro,s (If Uifierrnl from lor.,alion)
MA
City(T'Own _
la.11 _
f ip t";o<Jr
t ` e
rrlepho7rs t`ti,,rr+f)r;r
B. Pt.JM�Dir g record
1 Date of Pumping e ���� — 2 QUs amity Pumped
C;allons
3. C 0 M ponent: CesF toolSeptic
cjhl 'i'�nk �] Grease Trrap
(_) Other (descril)ey __...._.
4, Effluent Tee Filter presprif? (_.-.� Yes __f No f yes~:, wa.s t C; (..-.caned? [_J )'es t,tn
5, Observed condition of component prwnped:
6 Systerr7 PurT1[7or1 By:
Dave Tine Y . --_-_-._.__.___. V1 ,r, 1l�1y\C� - Mass 1AD31Z
8r71e \!C (,Ir l ir,t,r7.r Nurr7ber
Bafeson Enierj)rises, Inc
Company
7, - on wtaerc, cc>nCerlts vve;rC clisposrcl.
COLS
Srgn4alu ' of lau(e!
`>ICyna(tur. of Ftr.t,tyivkitl Facility (or allaclr f;tir,ilrly rcceif+()
t5ft,mA.dot'', 11/12 sy;Iem Pumping Fd rzrrrrr,1 � G'su,rr i nl ,