HomeMy WebLinkAbout- Septic Pumping Slip - 30 BRUIN HILL ROAD 5/2/2019 RE C Eli, i� D
Commonwealth of Massachusetts
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Andover
City/Town ofNo,,"
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System PumpingRecord s1�111101-�'Tl,-,i ef\�,\i v
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 hers. Before using this fora,, check with your
local Board of Healthto determine in the fora they use. The System Pumping Recordmust be submitted t
the local Board of Health, r other approving authority wit in 14 days from tl umpling date in
accordance with 310 CMR 15.351. r
A. Facility Information
l
Important:When,
filling out forms 1 System Location:
n the computer,
30,Bruin Hill Rd
use only the tab
key to move your Address ..
cursor-do not Norte Andover
use the return
City/Town State, Zip Code
2. System Owner:
Oki Pare Ferullo
Name
Beaus
d'dr s if different from location)
Same
City/Town State Zip Code
- a .
Telephone Number ....,,�
B,, Pumping Record
5 9 1500
1. Cute of Pumping 2 Quantity Pumped:
t Gallons
3. Component: El Cesspool(s) Septic Tank Tight Tank Grease Trap
Ej Other(describe): �.... �
. EffluentTee Filter present? Yes bZ No It yes, was it cleaned? 'Yes No
5. Observed' conditions of component upped:
Tank has not been puniped in several y1 ears.Removed solid materials to best of abilities.
R System Pumped By:
r�rrrr T79928
Name VeNcle License'Number
Thnothy A.Giard Plumbing&Heating
Company
J
7. Location where contients were disposed:
Greater Lawrence Sanitary District
r
r
Signature of Hauler late
l
Signature of Receiving Facility r attach facility receipt) Date
t5f rm4.,d ,11/12 System Pumping Recorde legs f 1