HomeMy WebLinkAbout- Septic Pumping Slip - 42 OLD CART WAY 6/4/2019 i
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Commonwealth of
Massachusetts
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City/Town of North Andover
System "IRecord
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,Ny Form r r !Nr.i0rhl I �I n.'
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DEP has providecIthis form 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 form, chec with youir
loll Board of Health to determinethe form they use.,The System Pumping Record must be submitted t
the local Board'ofHealth or other approving authoritywithin 14 days from the pumping date in
A. Facility Information
Important:When
filling out forms 1. System Location:
n,the computer, Cart.Way
use only the tad �2
key to move your Address
cursor do not North Andover MA 0 1 5-63 2
use the return,
City/Town State Zip Code
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2. System Owner.-
Katie Kennedy
Naas
address if different from location)
it /Toni Stag Zip Code
3 -2 - 59
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Telephone Number
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B. Pumping Record
�I. t Pumping ���1 � �1 ;�. Quantity Pumped'- �� � I
DateGallon
3. Type of system: C ss 1 s Septic Tan Tight Tank Grease Trap
El Other 'e eri e :
. Effluent Tee Filter pressrun' Yes Z No If yes, was it cleaned? Yes Z No
5. Condition of;system:
1
Goode system operating properly
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, System P ed B
Jason Elliott S71 4 37
Name Vehicle License Number
I► str and Elliott Services LLC-DBA Jason
Ellli itt Pumping
. Location where contents gars disposed:
GLS
5 21
�i urn of Hauler Date
EVig--n46re of Receiving Facility Cate
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