HomeMy WebLinkAbout- - Septic Pumping Slip - 57 MILL ROAD 8/17/2026 Town of Nofth Andover
Commonwealth of Massachusetts
� - City/Town of
w° System Pumping Record
:. F'crrrn a Health Department
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same es that provided here. Before using this form, check with your
local Board of Health to determine the form they 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 CMR 15,351, —..---.---------
HOUSE: front bac � sici� le�ight
A. Facility Information BUILDING: front back side rear Pt right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab 1,
key to move your Address
cursor-do not MA
keYe the return Ciky/Town _ _ ___—____. — State _ — —� Zip Code
2. System Owner:
Name
Address(if different from location)
M A___ _
Clty/Town _.—___ __. ____.__._. Stat _ __-__ Lip Codex —-- -
Telephone Number---.-,--
B. Pumping Record
1. Date of Pumping 2. uantityPum Pumped-,
Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tln>� -- Mass 1AA95E Mass 1AD31Z
Name Vehicle License Number
Bates nterprises, Inc.
Company
7. Location where contents were di
GLSD
Signature of HauEer Date
Signature of Receiving facility(or attach facility receipt) Date
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