HomeMy WebLinkAboutSeptic Pumping Slip - 56 SUGARCANE LANE 1/9/2018 �
Commonwealth of Massachusetts
_
City/Town of North
' VVDofN{]rfh Andover
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~°�="== Pumping�� ^ ~~°~^ " =~ H[A[D|ULFXR��ENT
Form
DEP has provided this form for use by|uoa| Boards of Health. Other forms may be used, but the
information must be substantially the name as that provided hona. Before using this form, check with your
|Voa| Board ofHealth todetermine the form they use. The System Pumping Record must besubmitted to
the |uoe| Board nfHealth orother approving authority within 14days from the pumping date in
accordance with 31OCPWR15.351.
A, Fac~0^tyUnGmrmat-on
Important:When
filling ut forms 1. System Location:
on the computer
use on ��b,
�the
56 Sugarcane Lane
key mmove your Address
cursor do not
North Andover MA 01845-3248
use the return
_^.
City[Town State Zip Code
2. System Owner:
~---�
Lisa Staff
Name
,kddress(if different from location)
978'688-2664
ephone Number
---------
B. Pump~ng Record
11/9/2017 15O0
1. Date ofPumping 2. QuanU1yPumped:
ons
3. Type ofsystem: [l Cesspool(s) Septic Tank Fl Tight Tank [l Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? Yes No If yes,was it cleaned? Yea No
5. Condition ofSystem:
Good, ba Uproperly
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:
GL8O