HomeMy WebLinkAboutSeptic Pumping Slip - 60 CAMPBELL ROAD 10/17/2017Commonwealth nfMassachusetts
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System Pumping
Record
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OEPhas provided this form for use bylocal Boards ofHeaUh.OUherhnmamaybeused.bu the
information must be substantially the same as that provided here. Before using this fonn, 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 orother approving authority within 14 days from the pumping date in
accordance with 31U{}K4R15,351.
A Facility Information
System Location:
60 Campbell Road
Address
North Andover
2. System Owner:
[Nu'SanLian0MA
Name
*uumx (rmnamot from location)
��T��- ------- State.
878'885'5309
Telephone Number
01845
B.Pump^ng Record
1. Date of Pumping
9/25/2017
Date
3. Type ofsystem: El Cesspool(s)
R Other (describe):
4. Effluent Tee Filter present?
5. Condition ofSystem:
�Good, �system operating properly
6. System Pumped By:
Jason Elliott
2. Quantity Pumped:
Septic Tank F-1 Tight Tank n Grease Trap
Yes F0 N o If yes, was it cleaned? Yes 04 No
Name
|vesterand Elliott Services LLC'DBAJ000n
Elliott Pumping
7. Location where contents were disposed:
GLSO
mURM-mmHauler
Signature mReceiving Facility
S/2S/2U17
mfonn4.uoo 03/06 System Pumping Record ` Page Imo