HomeMy WebLinkAbout- - Septic Pumping Slip - 781 WINTER STREET 8/21/2026 Town of Nofth Andover
Commonwealth of Massachusetts
City/Town of SEP 14 2626
System Pumping Record
Farr-n 4 xo if
" Department
DEP has provided this form for use by IocaP Boards of Health. Other forms may be used, but the
information must be substantially the Barr e as 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: fron back side rear left right
_...__.._.-_.__�_________._.__.._
A. Facility Information BUILDING: front back side rear left right
Important;When
DECK: under
filling out forms 1. System Location:
on the cornputer,
use only the tab f r✓'
key to move your Addr ss —
cursor-do not c MA
usethe:return _-_---_-- -_,_._. _.—_ ..--___ ..____-_—_ __.._..__..- ---------
key. --_----
City/Town State Zip Code
�,..__..-_. 2. System Owner: /
�, ,1 1<0 oa
- Name
Address (if different from location){M
MA
City/7own State p.. �Code
Telephone Number -___ _____—
B. Pimping Record
I. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) ] Septic Tank ❑ Tight Tank ❑ Grease 1-rap
❑ Other (describe):
4. Effluent Tee filter present? ❑ Yes �"No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of compo en
& ystem Pumped By:
CDave1"ine Mass 1AA95E — asset~....
Name Vehicle Lirense Nur
son Enterprises, Inc.
Company
7. Location where contents were disposed:
C.(SDSiof Wainer - --- --- Date
Signature of Receiving Facility(or attach facility receipt) Date
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