HomeMy WebLinkAbout- Septic Pumping Slip - 555 BOSTON STREET 6/4/2019 iu///rho
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/Town of North Andover
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System Pumping, Record
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.M Form
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DEP has provided this form for use by loca,l Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided bare. Before using this form, check with your
local Board of health to determine the forms they use. The System Pumping Record rust be submitted t
the local Board of Health or other approving authoritywithin 14 days from the pumpng, tie in
accordance with 310 CMR 15.351.
X, FacilityInformation
Important:When
filling out forms 1. System ILocation:
on the computer,
use only the tad 5515 Boston ,'street
key to move your Address,
cursor-do not North Andover MA 01845-632
use the return
Ivey,.
City/Town State Zip Code
2, System Owner:
Geoffrey Road
.AIJ Address if different,from location)
Cityfrown State Zip Code
5 ®6 -75, 5
Telephone Number
B. Pumping
1. Its of Pumping 5/3/2019 t� 2. Quantity Pumped: 1500
Gall
ons
3 'Type of systerno Cesspool(s) Septic Tank []' Tight Teak Grease Trip
E Other(describe) ..-„
. Effluent Tee Filter present Yes N o If yes, was it cleaned? Yes No
5, Condition of System:
Good, system operating properly
. System Pumped
Jason Elliott S71 3
Name Vehicle License Number
Iv st+ r and Elliott Services e LLC-DBA Jason
Elliott Pumping
. Locationwhere contents were disposed:
G,LS
5/3/2019
S7ig'rgu're of Hauler Date
_�i ftirf Receiving lint
Date!
t5for 4.d .03/06 System Pumping Record-Fags I of'8