HomeMy WebLinkAboutSeptic Pumping Slip - 61 CARLTON LANE 1/9/2018 6 f`. D
t Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
V
Farm 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the t
information must be substantially the same as that provided here. Before using this form, check with your J
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 61 Carlton Lane
......
key to move your Address
cursor-do not North Andover MA 01845
use the return _ __ _......__. .. _. _........__...._........
_
key. City[Town State Zip Code
2. System Owner:
teb
Michele Matranga
Name _...�w.._ ...
rertem
Address(if different from location)
CityFrawn State Zip Cade
978-729-8911
Telephone Number
B. Pumping Record
1500
1. Date of Pumping 11/22/2017 ____... 2. Quantity Pumped: also
_.... _�
Date Gallons
3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): _ _ ..................._ _.----–
4. Effluent Tee Filter present? Yes ® No If yes, was it cleaned? Yes ® No
5. Condition of System:
Good,system operating properly
6. System Pumped By:
Jason Elliott 571437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping_,,
7. Location where contents were disposed:
GLSD
__. _.._..d... .. __
11/22/2017
Si ure of Hauler Date
Signature of Receiving Facility Date
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