HomeMy WebLinkAboutSeptic Pumping Slip - 7 LACONIA CIRCLE 6/29/2017 Commonwealth of Massachusetts fkccf-
ED'
City/Town of North Andover 11 It
System Pumping Record
Form 4 t4c)KI�A NN0
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 7 Laconia Circle
key to move your Address
cursor-do not North AndoverMA 01845-3304
use the return
key. City/Town State Zip Code
2. System Owner:
rab
John Kacvinsky_
Ne---me-"-
lBdLYR
–-.11 . .... .....
Address
ddr es s(if different f r om location)
....................
Cityrrown State Zip Code
617-721-5186
...........
Telephone Number
B. Pumping Record
1. Date of Pumping 5/5/2017 2. Quantity Pumped: 1500
Date Gallons
3. Type of system: ❑ Cesspool(s) Z Septic Tank n Tight Tank El Grease Trap
n Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes E] No
5, Condition of System:
Good, sys�tqloperating
_pr
— _ 9perly
6. System Pumped By:
Jason Elliott 571437
-Name— Vehicle License Number—
Ivester and Elliott Services LLC-DBA Jason
-Elliott Pumping
7. Loca 'en.,where
w here contents were disposed:
S
,LS;
.........................----------------
5/5/2017
Si`�aature of" soler Date
-Signature"o'f"-Receiving-F-a"c i 1-1 t y- Date
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