HomeMy WebLinkAbout- Septic Pumping Slip - 159 FOREST STREET 9/7/2018 ����0 7�����
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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 orother approving authority within 14 days from the pumping date in
accordance with 310CPNR1U51.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the
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key mmove your Address
cursor-do not
NorthAndoverMAO1845
use the xxu,n
key. c��f6�� o�� Zip Code
2. System Owner:
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Name
ress(if different from location)
State Zip Code
978-482'5081
Telephone Number
B. Pumping Record
1. Date ofPumping 8/8t2018 2� Quantity Pumped: 1500
DateGallons
3. Type ofsystem: Fl Cesspool(s) Septic Tank R Tight Tank Fl Grease Trap
Fl
Other(describe):
4. Effluent Tee Filter present? Yes No |fyes, was itcleaned? Yea No
S. Condition ofSystem:
Good, system operating
G. System Pumped By:
Jason Elliott S71437
arne Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSO