HomeMy WebLinkAboutSeptic Pumping Slip - 207 FARNUM STREET 11/17/2017 (2) ����������
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System Pumping Record Form 4 MEAO1iDERARTMENT
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 ofHealth todetermine the form they use. The System Pumping Record must besubmitted tm
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31UC[WR15.35i
A, Facility Information
Important:When
filling t forms 1. SyutomLooaUon:
on the�vvn��e�»� 207FarnumStreet
key mmove your xuum^o
u"mu,-do not
North Andover [WA O1845
use mv�mm
key. ~^`^'~`''` State Zip Code
2. System Owner:
�--` Mixon
Name
Address(if different from location)
Zip Code
978-700-5462
B. Pumping Record
10/10/2017 1508
i. Date ofPumping 2� C>uantNyPumpmd�
Gallons I
3. Type ofsystem: [l Cesspool(s) Septic Tank Tight Tank Grease Trap
M Other(describe):
4. Effluent Tee Filter present? Yes No |fyes, was itcleaned? Yes No
5. Condition of System:
Good, system otiproperly
0. System Pumped By:
JamVnB|iutt S7i437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott i
7. Location where contents were disposed:
GLSO
10/10/2017
aSig"1*ure of Hauler Date
ignature of Receiving Facility Date
t5mnn4.uoo^0306 System Pumping Record^Page 1u11