HomeMy WebLinkAboutSeptic Pumping Slip - 295 CAMPBELL ROAD 1/9/2018 �����������
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—� --- Pumping~� ' -- ' — HEAL HDEPARTMEN7
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 ofHealth 0odetermine the form they use. The System Pumping Record must bosubmitted to
the |oom| Board of Health orother approving authority within 14 days from the pumping date in
accordance with 310CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the mmun��emu� 205Campbell Rmad
key mmove your *udrmw
cursor'««not North Andover MA 01845
use the return
key. City[Town State Zip Code
2. System Owner:
~---~ Robert Bombur
Ajdress_(-If different from location) ------
1-078-687-1825
%foiophone Number
B. Pumping Record
1. Date ofPumping 11/2/2017 2� Quandy
Quantity 1500
DateGallons
3. Type ofsystem: El Cesspool(s) Septic Tank [l Tight Tank Fl Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? Yes Z No Kyes,was itcleaned? Yes Z No
5. Condition ofSystem:
Good, system operating |
8. System Pumped By:
Jason Elliott S71437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
11/2/2017