HomeMy WebLinkAboutSeptic Pumping Slip - 432 SALEM STREET 6/7/2018 Commonwealth of Massachusetts JUN 0 5 ?018
w City/Town of North Andover TOWN �1� i.�i� 1gANi�)OVER
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w° System Pumping Record
Form 4
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 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 farms 1. System Location:
on the computer,
use only the tab Salem Street
key to move your Address
cursor-do not North Andover MA01845
use the return — _. --
key. City/Town State Zip Code
r�
2. System Owner:
Robert Broussard
Name
ransn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
5/9/20181000
1. Date of Pumping - ---- 2. Quantity Pumped: -
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
I
5/9/2018
Si ure of Mauler Date
�_ -. .,.... .._ ......_._... ......._ — --
Signature of Receiving Facility Date
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