HomeMy WebLinkAbout- Septic Pumping Slip - 50 CHRISTIAN WAY 5/2/2019 IIIAMMRh slid///0✓aJ«ii iir i �i p'i/Ai%�lla,POORuommonwea,ith of Massachusetts
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City/Town of North, Andaver ✓N f
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SystemPumplongRecord �,II„ III. �,I�,,,, o „n1""l"I,
�Form,
DEP has proviided thi's form for use by local Boards of Health. Other forms may be used, but the
information must t s n i ll the same as that provided here. Before using this form, check wlith your
local' Board' of Board' Health to determline the form they use. The System Pumping Record mist be submitted t 1
the, laical Board of'Health or other approving authority within 14 days from the pumping date in 1
accordance with 3110 MR.. 15.351.
A. Facility, Iniformation
Important:Where,
filling out forms . System, Location"
on the computer,p 50 Chrmstman W
use my the t n m,
key to move your Address
cursor-do not North Andover MA 01845
use the return
City/Town State ,dip Code
2. System Owner:
Michael C l nt ni
'
amie
Mrft
Address f different from location
City/Tiown 'State Zip Code
508-494-7287
Telephone Number
B. Pumping
1500
�1. Date Pumping 2. Q r��tmtPumped.*
CateGallons
I Type of system* Cesspool(s) Z Septic Tank El
Tlght f irm Grease Trap
El Other(describe):
1
t
4 Effluent Tee Filter present Yes Z No if yes, was it cleaned Yes Z No
5 Condition of System:
n:
Good stein operating properly
6. System r pe ....
Jason Elliott S7 3
aMe VehicleLicense gum r
livester and llictt Services ices C- Jason
Elliott Plumping
7. Location where contents were disposed;
S
4/52 �1 9
� ..........
i ur off"Haul r Cate
Signature f Recel,living Facilityt
t5if r n , #03/06 System Pumpling Record, Page 2 of