HomeMy WebLinkAboutSeptic Pumping Slip - 1289 SALEM STREET 6/6/2018 Commonwealth
^�[)D0��[)[l\&1���/u ' `�/ ���~ �~ ~ --
/`'+«/T'(]VV[l of North /\[lrfoVer ^\UN 0
System Pumping Record
VER
OF��mr""~-
�K��M� z1 ^w~~ � HDGF��\Mo~`
^'r -
DEP has provided this form for use by local Boards of Health, Other forms may beused, but the
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 310CMR 1S.351.
---------------
A. Facility Information
Important:When
filling out forms I. System Location:
on the use �e�u� 1289 Salem Street
key mmove your ^uum^x
uvmo,'do not
North Andover [WA01845
use the return
xrv, City/Town State Zip Code
2. System Owner:~---~ K4|ohee| Guo||
Name
State Zip Code
B. Pumping Record
1. Date Of Pumping 5/8/2018 2� Quantity Pumped: 1000
DateGallons
3. Type ofsystem: El Cesspool(s) Septic Tank Tight Tank Fl Grease Trap
R Other(describe):
4. Effluent Tee Filter present? Yes Z No |fyes, was itcleaned? Yes Z No
5. Condition ofSystem:
Good, system operatingproperly
6. System Pumped By: �
�
Jason Elliott G71437
Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason �
Elliott Pumping
7. Location where contents were disposed:
GLSD