HomeMy WebLinkAbout- Septic Pumping Slip - 461 SUMMER STREET 5/7/2019 Commonwealth of Massachus,efts
Cit,y/Town North Andover
System Pumping Record
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 bare. Befolre usinig this forma, check with your
local Board of Health to determine,the form they use. The System Pumping Record must be submitted t
the local Board of Health r other approving authority within 14 days 'r m, the pumping date in
accordancewith 310 CMR 15.3,51.
X Facility Information
Important-When
filling out forms 1. System Location-.
on the computer,
use only the tab 461 Summer Street
key to move your Address
cursor do not
North Andoveruse the return .n,, »,
City/Town 'State Zip Cod
2. System Owner-
Russell Bilodeau
Name
IE .,..,
Address,(if different from location)
City/Town Stag....� .dip Code
603548-4734
Telephone Number
B., Pumping ReI.
/26 2 9 1500
Cute of Pumping Date �� � ������mm���.��� 2. Quantity Pump �. ...........
Gallons
3. 'Type f s �st rru: Ce sp l s E Septic Tank Tight Tank E:1 Graves Trap
Other descrlbe ... w . ...,,,
. Effluent Tee,Filter pr�ese t Yes No If yes, was it cleaned? Yes No
5. Condition ofSyste
Good, system operating properly
6. System Pumr p d :
,Jason Elliott S 1 3
Name VehicleLicense Number
heater and Elliott Services, LLC-DBA Jason
Elliott Pumping
"., Location where contents were:disposed:
GS
26 2 9
Si Mr f H uler late
-Signature Receiving Facility Cat
t, f rm . ' ,, 3 System Pumping Record lugs I of 3