HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1432 SALEM STREET 6/8/2026 Town of North Andover
Comrnonwealth of Massachusetts JUN
15 r u 202
C l t y/Town of
7
ystern Pumping Record OaIh
Farm 4 ct"t
DEP has provided this forrn for use by local Boards of Health, Other forms rT1ay be used, but the
nformahon Must be substantially the ssrne as that provicie,d here, Before using this form, clI with your
local Board of Health to determine the forrn Ihey use The Systern Purnping Record must be submitted to
the Ucal Board of Health or other apprc>vi g authority widhin 14 days from .he pumping date in
accordance with 310 CMR 15,351, — ---
_.. _ HOUSE rent acfk stale real- IEft cls, t,,
A. Facility InforrTlcatiofl BUILDING: "ff6.nt back side rear left right
Important: Whan DECK: (-1rldr:'r
filling out farms 1. System Location,
on Me computer,
ise only the tat
key(a move your Fr,d<Jaas4 � /
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use the relurn --
key. ,ely(rewr, _ 4tale Zip code
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Address (if d-iP'(e----rpni from lor,allvrr7 --
MA
C{ly/`town date Zip Code
Tole f7one Number
—._..._-- _._- _..__. _ .......
B, Pumping Record
1. Date of Pumping rate _.. _ --- 2. Quantity Pumped _ -�_.._ _.......
Gallons
3. Componer)t. .] Cesspool(s) eptic 'Fa nk [ Tight Tank Grease Trap
[] Other (describe): _ _..
4. EfPlUent Tee Filter present? [.] Yes [L}'r4o If yes, was it cleaned? ❑ Yes [.] No
5. Observed condition of cf>i )ent pumped
6. Syst In P[° ped By
iJa e f Irlcxy.._ Mass 'IAA95E pass 1AD31Z
IklSr e WF Yvc;ir: t.lr,ense plumber
Ba�eson Enterprises Inc.
Car a
7 Qcallctrt vvherr coriter�ts were disposed
ST nature of Haute( _ _- .._ Date--._-_ - --
51gnature of Rey ew{nra'Facility (or aCt'gc1i (ar.,ihly n,ccIpl) (gat€.
l5lornn4.doc- 11112 `,yyslern Plot{rind Record rage 1 of 1