HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 743 JOHNSON STREET 6/1/2026 �L\ Commonwealth of Massachusetts
ism Town of North Andover
Cit own
System Pumping Record
Form. 4 JUL 7 2026
CEP has provided this form for use by lo--=! Boards-of Heal tn.ftr"M, ay be used, but the
t
inforr.mation must be substantially them na provided sam
e as t
nteck with your
Ho
ard of Health to deterrnine the for-TI they use. T-he Systeern, Purnping Record. must be submitted to
the local Board of: Health or o+-hsr aPrOving authOritYWllhin 4days 1- the pu7-n.ping date in.
accordance W;ti,310 CMS. 15.351.
A. Facility Information
Importaft When
filling out forms '1. System Location:
on the computer,
use only the tab 7 '-1
key to move your ticc -ass
Cursor-do not
use the return MA
key- cil�l own Stave Z:P Code
2. System Owner
°�rn=
Address(1,dlfffe.,er.t irons joagdon)
'- ylTown. state 2sp—code
Telephone NUZ-1-oar
B. Pum ing Record
.4. Date of Pumping- )DD(?�)
2. Quantity Purnpecl:
3. Ocmnoneni- icesspOOVW
I �M'
E--l" Crease Trap
Other'(describe):
4. Effluent'r e ;:liter presan�'7 e YssN No
!--ye-�` Was IT'C"ean'sd? �77 Yes M No
5. Observed co.ridi-Lion Of Component pur- r)edi:
r, ( .
RILIOZ71 is 110,11-tiMriint- 11 Of this eStfMated
�E e OILLEDi-20 Nr)t r=Q?- ---- 'ble beyond the date above.
S. System Pumped By:
J&S Deve�' L:CenSe NUrrbs,�
aervin'. :OPM3-e-7-COrD- CVb/a
'7- Loc2tjon-whare resrtt of we-re
----- Mental, LLC
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