HomeMy WebLinkAboutSeptic Pumping Slip - 32 CHRISTIAN WAY 8/6/2018 ����
Commonwealth Massachusetts m�����~V����
��(]D100C}M\A/���/u / ~�/ /v/����S��(�. .U����``��
City/Town Of North Andover AU(1 � �
�� 9M1R
System Pu00�^n—� R�����d T��OFN0RTHAN�VER
' H�2P��[�ENT
FK�rKO4 HEALTH
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 besubmitted to
the |ovm| Board of Health orother approving authority within 14 days from the pumping doh in
accordance with 310CYNR16.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
onthe computer,
32ChrisUanVVa
unoon��e�b
key uumove your Address
oumor-do not
North Andovar [NA 01845
use mvmmm
key, City/Town State ^''``~~
2. System Owner:
~---�
Joseph Bn
Name
Address(if different frorn location)
City/Town State Zip Code
978'566-3808
Telephone Number
B. Pumping Record
7/11/20181500
1. Date of Pumping 2. Quantity Pumped:
3. Type ofsystem: Cesspool(s) M Septic Tank El Tight Tank El Grease Trap
LJ Other(describe):
4. Effluent Tee Filter present? You No |fyes, was itcleaned? Yes No
5. Condition of System:
Good system (iproperly
G. System Pumped By:
Jason Elliott S71437
Name hicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSO
7/1112018
,5mnm4.uuo^03106 System Pumping Record^Page 1wa