HomeMy WebLinkAbout- Septic Pumping Slip - 50 STONECLEAVE ROAD 5/2/2019 ' Commonwealth RECEI
ED
City/Town of North Andover
FA
sty in Record
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C EP has provided this fora,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 fora, check with your
local Board of Health to determinethe,fora they use. The he System Pumping Record must be submitted t
the local Board of'Health r other approving uth rit within days from the pumping date in
accordancewith 310 CMR 15. 5 .,
A. Facil'ity Information
Important:When
filling out forms 1. System Location
on the comp
50, Stoneclea,ve Road
use only the tad
Mr
key to move your Address
cursor-do not North Andover a 1, 6,145
use the return ..�
City/Town State Zip Code
. System Owner:
Marilyn Joyce
Name
Address(if different from location),
Cit frown State Zip Code
97 - 8- 76
Telephone Number
B. Pumpling Record
5/2/20,19
1. Cute of Pumping 2. Quantity Pumped:
Date Gallons
3. Component:, Cesspool Septic'Tank Tight Tank Grease Trap
E] Other(describe): ..........� .. .. mmmm... ....
4. Effluent Tee Filter present? Yes No if yes, was it cleans Yes l
5. Observed condition of component pumped4
Of scum layer- 41" slud . Normial liquid leve
6 System Pumped
Anthony Mottolo V21 ,
Name Vehicle License Number
John Zanni Pumping Co., Inc,
Company
7. Location where contents were deposed:
GLSD
5/2/2019
Signature of Haull r Cate
Slignature of Receiving Facility r attach facility receipt), [date
t5form4.d *11112 System Pumping Record Fags I of