HomeMy WebLinkAboutSeptic Pumping Slip - 507 SALEM STREET 10/17/2017Commonwealth nfMassachusetts
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System Pumping —
Form
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TOWN OFNORTH ANF)0VER
uE'AL\HDEPARTMEN|
DEP has provided this form for use by local Boards of Health. Other forms may be used, butthe
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 |oou| Board of Health orother approving authority within 14 days from the pumping date in
accordance with 31OC&1R15.351.
A Facility Information
Important: When
filling out forms 1. System Location:
unthe computer,
use only the tab 507 Salem Street
key to move your ^um°ss
cursor do not
North Andover
use the return
key
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2. System Owner:
Ruisanchez
Address (if different from location)
oty[To"
B. Pumping Record
State Zip Code
305-725-8381
0/21/2017 1. - - Date of Pumping Date 2. Quantity Pumped: -150U
3. Type of system: El Cesspool(s) 1112 Septic Tank 0 Tight Tank El Grease Trap
R Other (describe):
4. Effluent Tee Filter present? 103 Yes No If yes, was it cleaned? 0 Yes No
6. Condition ofSystem:
Only cleaned filter 0/21 Good, system operating properly
G. System Pumped By:
Jason Elliott
Name
|veotevand Elliott Services LLC'O8AJason
Elliott Pumping
7. Location where contents were disposed:
GLSD
S71437
V�h-ic-l"e'Lice"'nse' Number
Sig,-mnmHuuler
Signature ofReceiving Facility
Q/21/2O17
Date
mfom4.clvr-03/0System Pumping Record ^ Page 1me