HomeMy WebLinkAboutSeptic Pumping Slip - 302 REA STREET 10/17/2017'
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System Pumping Record
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Form
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 orother approving authority within 14 days from the pumping date in
accordance with 31OCyWR15.351.
A Facility Information
1. System Location:
302 Rea Street
Address
North Andover [WA O1845-4821
�Cit�StateTmwn -------- n,v z�Code
2. System Owner:
Walter Gill
Address (if different from location)
oity[Town
State Zip Code
978-975-1022
Telephone Number
B.Pump^ng Record
i. Date of Pumping
9/6/2017
3. Type cfsystem: El Cesspool(s)
El Other (describe):
2. Quantity Pumped:
Z Septic Tank M Tight Tank El Grease Trap
4. Effluent Tee Filter present? Yes 110 N o If yes, was it cleaned? Yes 0 No
5. Condition ofSystem:
Good, system operating properly
8. System Pumped By:
Jason Elliott
|vooturond Elliott Services LLC-OBA Jason
Elliott Pum i
7. Location where contents were disposed:
GLSD
Vehicle License Number
.. . .................... . ......
0/8/20i7
Sig �—Ure of Hauler Date
Signature mReceiving Facility
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