HomeMy WebLinkAbout- Septic Pumping Slip - 110 FARNUM STREET 1/8/2019 ���
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����*� Pumping
Record
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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 |uoa| Board of Health ur other approving authority within i4 days from the pumping data in
accordance with 31UCK4R15.351.
A~ Facility Information
Important:When
filling out forms 1. System Location:
on the use �e�u� 11OFannumStreet
keym move your Address
cursor do not North Andover MA 01845
use the return
City/Town Statez/pouu�
_'.
2. System Owner:
�---� Laurie Stevens
Name
City/Town State Zip Code
078-807-0183
_
Telephone Number
B. Pumping Record
12/14/2018 1500
1. Date of Pumping Date 2. Quantity Pumped. Gallons
[�
3. Type ofsystem: �~ Cesspool(s) .��� Septic Tank �[�� Tight Tank �Fl
� Grease Trap
L] Other(describe):
4. Effluent Tee Filter present? Yes No |f yes,was iicleaned? Yes Z No
5. Condition of System:
Pump float sticking needs | Good, to Mproperly
G. System Pumped By:
Jason Elliott S71437
Vehicle License Number
|ves&mr and Elliott Services LLC-DBAJason
Elliott Pum
7. Location where contents were disposed:
GLSD