HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 120 HAY MEADOW ROAD 6/12/2026 r CCor!�rnonwealth of Massac; -IL,Isetts Town of North Andover
City/Town of
System Pumping Record JUL _ 2026
;4= Forifn 4
Health Department
DEP has provided this fcm'n for us(:' tag IUCcaI Boats of Health, Other forms rrlay be used, W the
infornration must de substantially the sarne as thaf provided here, BPfore uSing Ihis farm, check with your
local Board of Health to determine the forr-n lhr.,y use The System Pumping Record n'aust be subrrlitfed to
the local Board of Health or other apProviny <:iuthOrity within 14 days from -,he pornping date in
accordance with 310 CMf3 1 1,51 -.._ ----.11 .- ..._-_. -_-_._ _ _
HOUSE front d
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A. Facility information BUILDING, front b ~rar.k side rear left, rigs-At
{rrportant: M)on DECK: under
filling otA forrns 1. `7ysterll Locatl r'
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use only tho (ab M (�! �_._.. . ?�
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Pumping Record
1. Date of Purn InM =._
p g Dede... -- .-- -- 2 Ouantity Pumped.
Lallans
'r
3. Component: El Cesspools) K-�eptic "lank Tight Tank ❑ Grease Trap
Other (describe)
4. Effluent Tee Filter present? (,..� Yes [Vkjo If yes, was it cleaned? ❑ Yes No
S.Lon
erved condition of Conipooent pu ni pHd:
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f51{.7 e ci E3 y
V�;hicae LICE nse tot tl rY1 t7ererprises, Inc.
r ompany
y Location ear disposed:
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lyn8turc, of hiaule;r f_Snle
Signature of Receiving'Facility racility (or eattacia 6acifty rre<:rtip1}
15iorm4.doc• 11112 Syste rn f urnping Recorrt P qje 1 of 1