HomeMy WebLinkAbout- Septic Pumping Slip - 345 BERRY STREET 6/4/2019 9'N�
Ji y j It
Commonwealth of Massachusetts
a
City/Town of North
a, Andover
nd* ,
Ya
System hum i Record ce,
� Ck'
Form
EP has provided this fora for use by local Boards of Health. Other forms may be used, but the
information must be substantiallythe same as that provided here., Before using this,�f rr , check with your
local Board of'Health to determine the fora they use. The System Pumping Record must be submitted t
the local Board of Health or other approving authority within, 14 days from the uur lira date in
accord an ce with 3101 C M R 1 5.351
l
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 35 err ,street.
key t r ddr
our l" .,,
:
cursor-do not North Andover �1 5
use the return
W,,,,.....,,. ,,.
Ivey. Cityfflown State Zip Code
2. SvsterruOwner:
Jeanmarle Gouldre cult
Nam
few
Address(if different from location),
CltyFro rn State Zip Code
978-457-28,78
..........„ . m..........
� .
Telephone Number
B. Pumping
52 21 500
1. Date of'Purnping Cate 2 Quantity Pumped: Gallons
3. Type of system: Cesspool(s) Z ,Septic Teak El Tight Teak El Grease Trap
E] Other r(describe),: w. .... ..,,,M mmnnry.............mn
. Effluent Tee Filter present? Yes Z No If yes, was it leaned Yes Z No
. Condition of System-
Good', system operating properly
f
. System Pumped By:
i
Jason Elliott. S71 3
Name l l License n Number
r
Wester and Elliott Services L,LC-DBA Jason
Elliott Pumping
1
. Location where nt nt�s were disposed:
GLS
52 1 2g 1 g
l ure of Mauler bate
,Signature f Receiving Facility Date
t5f rm4. nn*03/06 System Pumping Record Page I of