HomeMy WebLinkAboutSeptic Pumping Slip - 154 REA STREET 11/17/2017 (2) �
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CC)[DD]onVVeaifh of Massachusetts
[~' of North Andover
MENT
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Pumping
RecordSystemup=~
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Form
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 local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310C[VIR15.35i.
A, Facility Information
Important:When
filling out forms 1. System Location:
on the mron��e�b� 154Rea Street
key mmove your Address
cursor-uvnot North Andover K4A01845
use the*tum Code j
u«v' City/Town State Z-
2. System Owner:
"----�
Christine Chiles
Name
078-390-3728
Tolopho-ne Number
B. Pumping Record
10/24/2017 1500
1. Date of Pumping Date 2. Quantity Pumped:
3. Type ofsystem: Fl Cesspool(s) M Septic Tank Fl Tight Tank El Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? Yea No Kyes, was itcleaned? Yea No
5. Condition of System:
Good, mU d
G. System Pumped By:
Jason Elliott S71437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pum i
7. Location where contents were disposed:
GLSD
