HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 485 FOREST STREET 6/19/2026 Town of North Andover
_`c•� Comc7�onwe ltt) of Ma ssachl_�setts
�fr City/Town of JUL °- 6 2026
=- - Sy
stem Pur Pecord
-.. Form
Health Department
DEP has provided this form for use by local Boards of F-iealth. other forrrr s may be used, but they
information must be substantially the., same as that provided here. Beforrs l_tsing lhf<r, fbrm, ChcC{<wilh yrrrir
local Board of Health to determine the form Ihey use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date In
accordance with 310 CMF-� 15,351
- H0L-isI- front Cackaside rr,rir efh right
A. Facility Information BUILDINCI: front back side reai lelfr ril ht
Important: When DECK: ur'1der
(Illing out forms 1. System Location,
can Ilrt-,C.ompulr�r, �
u5 only thn tab
ke'y to rnovc;ycaur Address
cursor-do not MA
arse the return __. _ ° .-_._ _._ _.___ ._._._._
Cit Crown -- - _ _._
rey , ale Zip Code
2. System owner:
VV
-- ----._...- - ---- _._—----
anrn /J
rosy (if di ferenl from location)
MA
Cityrrown lair
elr?phonc,. Number
B. Pumping Record
1. Date of Pumping «.I�, -��9 ___.._ Quantity
p 9 �.2 P i.,m p e d:
Gallons
3, Component: E-71 Cesspool(s) _I Septic Tank p ( Tic�tni Tank ❑ Grease Trap
�.� Other (describe):
4, Effluent Tee Filter present? (- f Ye.s _) No If yes, ways it cleaned? (.__) Yes (�) rlo
5. Observed condition of.cornponent p�.arnped:
6. System PiAmped By:
Dave TIneL—___-__- ---- -- -- ___._.___-_.._-_---_- ...__ Mass 1�95 Mass 1AD317
_ -----------___----- -----
Name vehicle L.iCp�nEpe a nk7rr
eateson Cntervises, Inc _-------------.------- _--.-__----___
Company
7. alion where contents were clispo;>e(1
Sigb'J� Hauler Dale ------
_.
signafuns of RFceivinct FaclRy (o( i(tach facility rc,ceip:)
l5forrnl,doc• 11/12
Syste rn F urnf>ing Record Page 1 of 1