HomeMy WebLinkAbout- Septic Pumping Slip - 125 GRAY STREET 10/9/2018 /
Commonwealth of Massachusetts
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System Pumping RecordTO�NOFNOKTHANO�VE�
— HEALO| DEP4RT�ENT
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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 nf Health todetermine 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 310CIWR15.351.
A~ Facility Information
Important:When
filling out m,nn 1. System Location:
on the computer,
use only the tab 125Gns Street
key m move your *vurev`
cursor-do not
North Andover MA 01845-8303
use mmmm/u
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key,
City/Town Zip Code
2. System Owner:
°---� Pau| Robbat
Name
Address(if different from location)
City/Town Zip Code
978-886-2861
B. Pumping Record
A�!U/2018 100O
1. Date ofPumping 2. 8uamUtyPumped�
Gallons
3. Type ofsystem: El Cesspool(s) 0 Septic Tank El Tight Tank El Grease Trap
FJ Other(describe):
4. Effluent Tee Filter present? Yes No |f yes, was itcleaned? Yee No
5. Condition of System:
Good,system operatingproperly
8. System Pumped By:
Jason Elliott S71437
Name Vehicle License Number
|vester and Elliott Services LLC-DBAJason
Elliott Pumping
7. Location where contents were disposed:
GLSO