HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 296 RALEIGH TAVERN LANE 6/26/2026 Town �North Andover
�:.,om��nc�r�wealtr7 Of Mass a 11 r���l_�sfw;tt
LF .
City/Town of JUL 6 2026
Y ng Rec orci
Form I-Ifth
Department
(:EP has, provided this form for use by local E: oatds of Heath. Other to(ms may be used, btll Cure
information nnust be substantivally the sarne as Mat provided here. Before using this form, cherck wi1C-r yc�u(
local Board of Health to determine the fon-n ff)ey usr.-, -1,t)e System Pumping Record must b(r cuf)mlfCe(j to
the local Board of Health or other of>f>rovinfi sulhorily wilhrin 14 day., frr::>rrr the pumping date,in
accordance watt) 310 t,mf� 1�) 351 ---
Pir)t1SfLL: front hFick side rea lef rip,,ht
A. Facility inforf atiot`1 P,tj _IDICrfG hom f,,)ac siCJe rear lef-i ripfl t
important:When D (K. under
oiling out forms 1. System Location,
on ff (� cornpWor,
use only Cher tah
key to rrrovr;your ArIC1r �
rumor - (Jo nol /
the (o(um MA
.y, y lip Code
2 >ystern Owner
r1r.1c1rnss (If different (roar Ic>cellon)
_ _. . MA
City/Town _ _
Stale ,...?Ir>Co
7elriphoab� ttlurr'tiber
E3, Pumping Record
1. Date of PLInn in. 1 `_ ._ ?__._ _...._, , /
C)�aIF l Quantity f� umped�, ---
C>allans
). COMponent, _-- C;esbpool(s) ) septic Tank (_) Tight Tank �re@see 1_r p
� C)tlrer (describe).
4. Effluent Tee Filter present? _ r'es C) If yes, was it cleuaned? ( Yes 17, No
5, Observed condition of corrIC r„rnOrr t Pumped.
6, System F't mpod By
Dave '1'In� ! 95E
-�,A lass 1AL�31�.
. Y .__ . . .__. M__rass 1 _.� _
Name
\lF Yrr In t.ir;r,n,e M1Jrrrril) r
eateson Enterprises, Inc
Company
1, Lou, Vn wtiefe con(e',nt3 vv( fc,
G'LS[.
Siynrsl rr�r � ler O,,rte, __.
Signature of Receiving f )c:ili(y(r)r aftnr.Yr fnr,ility recrif)I)
tr)forne4 dw.,,- 11/12 `system Pumping r e:,t:nrtJ f�arte 1 r l r