HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 58 SALEM STREET 9/10/2026 Town of
` = Commonwealth of Massachusetts North Andover
City/Town of EP 14 2026
LL ° System Pumping Record
t
arm 4 f
et Dep r�
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 as that provided here, Before using this form, checK with your
local Board of Health to determine the form they Lisp-. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within '14 days from the purnping date in
accordance with 310 CMR 15.351, — —__..._____. .W
HOUSE, front ac ��Side rear left igh
A. Facility Mnfornlc�tlori BUILDING: front `ack side rear left r'iu" t,
important; When
DECK: under
(filing out forms 1. System Location:
On the lcr, —
u s e only the the t tab
key to move your Address
cursor-do not
MA
use, the return
keY• City/Town State Zip Code
'--- 2. Systern Owner:
_._.- .._ _ ._.__ • C -_. .
tV a rpi e
renrn � �j
Address (if different from Vocation)
MA
Cfty[Town Sla Zip Code
Telephone Number
__..__.-.-----____._.
B. Pumping Record A.
1. Date of Pumping Date _P.._._ .__.__.—__-- 2. Quantity Pumped:
- Gallons
1 Component: ❑ Cesspoo1(s) 'eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? 0 Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of cornpanerlt pur ped.
6. rDave
m Pumped By:
1 in_e Veh Mass l_i
s 'lAA_ e.
g5E _Mass 1AD31Z
aeSon Enterprises, In - lc;le rens
o t{7any
r'
7. Location whp- e cont nts er disposed:
GLSD
Signature of Hauler Date
Signature of Fzeceiving Facility (or attach facility receipt) Date
t5form4.doc- 11112 System Purnping Record •Page 1 of 1