HomeMy WebLinkAboutSeptic Pumping Slip - 8 LACONIA CIRCLE 6/29/2017 Commonwealth of Massachusetts RECEIVED
City/Town of North Andover
System Pumping Record
Form 4 TOW�4 or f H ANDOVEER
6EAj_TH DEPARTM04T
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 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,
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab ?_.Laconia Circle
key to move your Address
cursor-do not North Andover MA01845
use the return
key. City/l own State Zip Code
2. System Owner:
Frederick Kulik
Name
ienvn
Address(if different from
CAtyli own State Zip Code
Telephone-Number
- -
B. Pumping Record
5/5/2017 1000
1, Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: F1 Cesspool(s) Z Septic Tank El Tight Tank F-1 Grease Trap
n Other(describe): ...........................
4, Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes F] Na
5. Condition of System:
...Good, system operating properly
6. System Pumped By:
Jason Elliott 571437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
-Elliott Pumping
7. Location where contents were disposed:
5 LSD"_
5/5/2017
i re-of Hauler Date
gv WIM
Signature of Receiving Facility Date
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