HomeMy WebLinkAbout- Septic Pumping Slip - 110 LACONIA CIRCLE 4/29/2019 i
Commonwealth of Massachusetts COT
City/Town of NORTH ANDOVER
f
System u Record
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urDAP has provided t �is form t r use y I li Boards 'He It . Other t rm s �� t
inforrr�ati n must� e s! st nti ll the same s that r i e ' here. 'Before using this, err �� c� with r
local Board of Health to determinethe form they us �. The System m i g Record rust be submitted,t
the local' Board of Hea,lth or other approving authority with in 14 days from,the pu mping date i nI
c rdance wilth 310 CMR 116.351.
A. Facility Information
Important:When
filling out forms 1. System Location.,
on the cornputer, 110 LACONIA CIRCLE
use only the tab
key to move your Address
cursor-do not H D VE 5,
use t�t� return Ci,t �'" n �����mm� ���� .���m.. . "tt m..mm�.... �� �.., . .....
�mm.mmm
Code
key,
2. System Owner-
CANDY KUKAS
Name
r
Address it different from location)
6_4 n State Zip,Code
Telephone Number
B.,
Pumping Record
22 19 1500,
1 w Date of innDate -��.�. 2. Quantity Pumped .� .m
3 Component: Cesspool(s) Z Septic Teak Ej °Tight ari Grease Trap
® Other
4. Effluent'Tee Filter present? Yes If yes, was it cleaned Yes N
5. Observed condition of component,pumped:
GOOD
6. System Pumped
JAY CURRIER 9 6
Name Vehicle License Number
S SEPTIC 1& DRAIN
o rrmn
7. Location .Dare contents were is l s '*
LS
2 '1 9
"i tre o a r Date
Signature of Receiving Facility. t r attach facility, to
t5f rm . o` /12 System Pumping Record.Page I of
