HomeMy WebLinkAbout- Septic Pumping Slip - 27 EAST PASTURE CIRCLE 9/7/2018 L\ Commonwealth of Massachusetts RECEIVED
City/Town of North Andover
. .............
System Pumping Record
Formtit:4 1 L) �"A'R'V NIENT
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 forms 1. System Location:
on the computer,
use only the tab 27 East Pasture Circle ............
............
key to move your Address
cursor-do not North Andover-.--.- MA -0 1845 ----
use the return
key, City/Town �Ipcode
2. System Owner:
Mark Vera
4--
-------
ame
renes
..............
Address(if different from location)
......................
.
City/Town State Zip Code
508-776-3820
Telephone-Number
B. Pumping Record
1. Date of Pumping 8/1/2018 2. Quantity Pumped: -1500
Date "dafton-s
1 Type of system: ❑ Cesspool(s) Septic Tank 0 Tight Tank El Grease Trap
El 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 .... 1
7. Location where contents were disposed:
GLSD
8/1/2018
Si ure of Hauler Date
Signature of Receiving Facility Date
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