HomeMy WebLinkAbout- Septic Pumping Slip - 305 BOSTON STREET 1/8/2019 Commonwealth nfMassachusetts
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System Pumping Record
Form "�C�VVN()FNDHJMANDQVER
`���o� HEALTHDERART�ENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
|nfnnnoi|on must be substantially the same as that provided hero. 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 |oom| Board of Health or other approving authority within 14 days from the pumping data in
accordance with 318C[WR15.351.
A, Facility Information
Important:When
filling out forms 1. System Location:
on �the computer, 305Bo�on8bmmt
u�m�Um��
key mmove your Address
cursor-do not North Andover MA 81845
use the return
»»v ~'~''`~' State Zip Code
2. System Owner:
~---� N|nh|toDza
Name
B. Pump~ng Record
12/27/2018 1500
1. Datem/Pumping 2. Quantity Pumped. Gallons
3. Type/fsystem: [l Cesspool(s) 0 Septic Tank Fl Tight Tank Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? Yes Z No |f yes, was itcleaned? Yes No
5. Condition of System:
Good, systoperatingem properly
6. System Pumped By:
Jason Elliott S71437
Narne Vehicle License Number
|veshsr and Elliott Services LLC-OBAJason
Elliott Pumping
7, Location where contents were disposed:
GLSO