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HomeMy WebLinkAboutSeptic Pumping Slip - 314 BOSTON STREET 10/17/2017Commonwealth of Massachusetts City/Town of North Andover System Pumping Record Form 4 REC 1VE I • TOWN OF NORNi ANDOVER DEpaamENT 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 314 Boston Street key to move your Address cursor - do not use the return key North Andover MA 01845-6344 City/Town State Zip Code 2. System Owner: Christopher Marshall Name Address (if different from Iocation) City/Town State Zip Code 978-686-6106 Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: L Cesspool(s) i4 Septic Tank ID Tight Tank Grease Trap 11] Other (describe): 4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes No 5. Condition of System: Good, system operating properly 1500 9/7/2017 Date 2. Quantity Pumped: 6. System Pumped By: Jason Elliott Name Ivester and Elliott Services LLC-DBA Jason Elliott Pumping 7, Location where contents were disposed: GLSD ure of Hauler S71437 Vehicle License Number 9/7/2017 Date Signature of Receiving Facility Date Gallons t5form4.doc• 03/06 System Pumping Record • Page 2 of 8