HomeMy WebLinkAbout- Septic Pumping Slip - 99 GRAY STREET 11/13/2018 ' . Commonwealth of Massachusetts
City/Town of North Andover Nov
._.. System Pumping Record TOWN or,NQ':ltk[H ?I �Alvlx)vc�F
Farm 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 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 99 Gray Street
key to move your Address
cursor-do not North Andover MA 01845-6301
use the return City/Town — -- _ State Zip Code
key.
rab 2. System Owner:
Michael Rosenberger
— .._....
Name
rnrn
Address(if different from location)
City/Town State Zip Code
978-430-1580
Telephone Nurrrber
B. Pumping Record
1. Date of Pumping 10/31/2018 -- 1000
p g Date 2• Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ 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 S71437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
1
_ 10/31/2018
miq—'re of Hauler Date
I
Signature of Receiving Facility Date
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