HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 21 EASY STREET 6/22/2026 Town of North Andover
w
Commonwealth of Massachusetts
City/Town of JUL - 6 2026
r I n� Re
cord
c o r cS stem P r
F o r tn
xr ' fle filth Department
DEP has provided this form for use by local E30ards of Health Other forms may be used, but the
information must be; substantially the; sarne as t17at provided here. Before using this form, check with yc:w
local Board of Health to determine the foFm they use, The System Pumping Record must be submitted to
the local Board of 1--lealth or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15 :351
HOUSE frL,nC rat.1< slrle r Y7r Ieft �P,ti
_ -
A. Facility Information - RL)II_uING front, hack side rear Vc It
mportaot:when DECK: u ndE r
(Filmy out forms 1. Systen") Location',
on[he cornputor, �
tab
rise Corm we your Addrcm ✓ --- - -._-___
cursor-do not _._.... __.._._ (V1A-
use the return
Key, Cltyfrown `al ale Zip CO( . � __._..... ..,..._..
2. Systern Owner
Na(i1F
Address (if different frorr7 location)
MA
City/iown 31;:iie dip(,o(le;
--
elepI)C)ne Ninnber
B. Pumping Record
'1, Date of Pumpinn _�� - .� ... ���_.._.._._-_ 2. Quantity Pumped: �
C7ale Gallons
3. Component: Cesspool(s) �. Septic Tank [ J Tight 'T"ar)k
g ❑ Creasy 1 r-�p
(_] Other (describe):
4, Effluent Tee Filter present? Yes _] No If yes, w,3s it cleaned? Yes
5. Observed condition of coi onenC F umped:
6. System Pkymped By:
5 j
Dave Tlr ray .__.... Ma 1 A�\ 5E M�AD
ttl8n1e; Vrs,Yrlr Ir l iCen,r., Nirrr >er
Bakeson Enterprises, Inc
company
7.OGL
or7 Miele contents welic dispo,�n[1:
Sly 1,tturc� f Hauler t7atr _._
Slynalure of Receeivinfl Facility (or aliacr i facility rt.coio�t) rate _- _--
(SfyrnA,doc, 11112 `system Pumping Record Page 1 of 1