HomeMy WebLinkAbout- Septic Pumping Slip - 507 SALEM STREET 9/7/2018 RECEIVED
Commonwealth
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City/Town of North Andover
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System Pumping Record DERIMW�tlT
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 31UCyWR15.351.
A~ Facility Information
Important:When
filling ut forms 1. System Location:
on the computer,
use only the tab 5O7Salem Street
key wmove your xuum,a
cursor'u»not North Andover /NA 10845
use the return
key. City/Town State Zip Code
2. System Owner:
~---= AntoninoRuimamohez
Name
Address(if different from location)
City/Town State Zip Code
305-725-8381
lephone Number
B. Pumping Record
i5UO
1. Date ofPumping 8/16/2018 2. Quantity Pumped:
Date
3. Type ofsystem: �[�� Cesspool(s) ~[�~ Septic Tank ���~ Tight Tank ^(�
� Grease Trap
n Other(describe):
4. Effluent Tee Filter present? 0Yes No |[yes, was itcleaned? Yeo No
5. Condition ofSystem:
Good, system operatingproperly
6. System Pumped By:
Jason Elliott S71437
Name Vehicle License Number
Wester and Elliott Services LLC'DBAJaaon
Elliott Pump'
7. Location where contents were disposed:
BLSB
�
ON8/2018
eSouremnaule, Date