HomeMy WebLinkAbout- Septic Pumping Slip - 50 CHRISTIAN WAY 5/7/2019 Commonwealth Massachusetts
City/Town of North An�clove
44
System Pumping
Form 4
DES has provided this forma 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 f Health to determine the form they use. The System 'iin Record rust he submitted to
the local Board of Health or otherapproving authority within 14 days from the pumping date in
acco 1
rd a ou ce with 310 C M R 15.351.
A. FacilityInformation
Important:When
filling out forms . System Location.-
on the computer,
use ont ,the!tab 5 Christian Wad
key to mope your Address
cursor not North Andover MA 01845
use the return
key. City/Town State Zip Code2. System Owner:
j
�I
Michael Cl; t i
---
Narne
Address if differ nt from location)
City/Town ,Mate Zip Code
508-494-7287
Telephone Number
B. Pumping
2 5
., date of'Pumping 2'. ntut Pumped.Nit+ Gallons
3. Type of system,- Cesspool Septic'Tank F1 Fight Tank El Greasy `trap
Other esrie .mm
. Effluent Tee Filter present? Yes Z No if "es, was it cleaned? Yes l
1
5 Condition f System-
Good,, system operating properly
J
. System Pumped By'.-
Jason
Name Vehicle License, u r
lv st r and Elliott tt Services LLG_C A Jason
llii tt Pumping
ing
'�. Location where contents were disposed:
l
G LS
1
51/ 9
Sig ur of Mauler Fate
Signature f.m Receiving NFacility
... W t .�m..m_.r,-„
f f rm .d , ,,, ; System umpin Record.Page 2 of 3