HomeMy WebLinkAbout- Septic Pumping Slip - 131 PHEASANT BROOK ROAD 11/13/2018 Commonwealth
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System Pumping Record
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Form
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 |ooe| Board of Health or other approving authority within 14 days from the pumping 6eto in
accordance with 310CKdR15.35i.
A' Facility Information
Important:When
filling Out forms 1. System Location:
on the computer,
131 Pheasant .
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cursor do not
North Andover MA Oi845-3372
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key. ~'`'''~`~' State Zip Code
2. System Owner:
~----^ Danielle Perry
Name
978-794-1727
B. Pumping Record
18/25/2018 1500
1. Date nfPumping 2. Quantity Pumped:
Gallons
3. Type ofnystem: Fl ComepnV|(o) Septic Tank Tight Tank Grease Trap
LJ Other(describe): ---
4. Effluent Tee Filter present? Yam No K yes, was |tcleaned? Yes No
5. Condition of System:
Good, system tiproperly
0. Qyuhsm Pumped By:
Jason Elliott G71437
Name Vehicle License Number
|vaotarand Elliott Services LLC'DBAJoaon
Elliott P i
7. Location where contents were disposed:
8LSD