HomeMy WebLinkAbout- Septic Pumping Slip - 7 LACONIA CIRCLE 6/4/2019 V//
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Mal
ulommonwealth of Massachusetts
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City/Town of North Andover
System Pump'M,g Record'
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I f m 4i a) s�,u
Form 4
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DE,P has provided this form for use by local Boards of Health, Other formis may be used, but the
information i must be substantially the same as that provided hers. Before using this form, check with o r
local Board Health t determine the f rm they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14,days fr r a the umpinug date in
A., Facility Information
Important:When
filling out forms I System Location:
on the computer, " Laconia Circle
use only the tad
key to rove your Address
cursor-do not North Andover Mai -33
Use the returnm ......M,. � mn., n
Cit;/Trw State: flip Code
. System Owner.
John Kaevinsky
N arra
few
.address If different from locution)
dtl y- own, State Zip Code
6171-721-5186
Telephone Number
B. Pumping- Record
5 1 1500
1. Datef Pumping �� 2. Quantity ur p : Gallons
3. Type of system: Cesspool(s) Septic T rek. El Tight Tank Grease Troup
El Other sears
. Effluent Tee Filter present? Yes Z
No If yes, was it cleaned? Yes N
5. Condition of System-.
Good, system operating properly
i
6.
,!t
System Pumped B :
Jason Elliott S7 37
...............
Name Vehicle License Number
Nester and Elliott Services LILC-DBA Jason
I Ili tt Pumping
. Location where contents were disposed:
-GS
512 2 1
f' ul' r Date
Sirwature of Recewing Facility
Date
t5f r m4. *03/06 System Purnping Record-Page l f
