HomeMy WebLinkAbout- Septic Pumping Slip - 754 BOXFORD STREET 6/4/2019 I
uommonwealthh of Massachusetts
21
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City/Town � .AndoverI
System Pumping
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Form
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P has provided this form for use by local Boards of Health. Other forms may he used, but the
information must be s,ubstantially the same as that provided here,, Befor using this form, check with your
local Board of Health to determinethe form they use. The System Pumping Record rust be ub ltt t f
the local Board of Health r other approving authority within 14 days from the pumping date in
accordance with 310 CMIR 15.351.
A. Facility Information
Important When
filling out forms, 1. System Location-
on
the computer,
use only the tab 754 BoxfordStreet
key to move yo r Address
cursor-do not North Andover MA 01845
use the return tate Zip Code
I
System Own r-
Amanda Geiger
me
Address It diff rent from location)
i
City/Town State ,dip Code
97 -31 - 1
....
.m .... ..
Telephone Number
B, Pumping
15100
1 Cute f Pumping Date.w.... �..�. .....mm 2. Quantity Pumped::
. Type of system: Cesspool(s) Z Septic Tank Fight Tank Grease Trap
. EffluentTee Filter present? Yes, No If yes,was it lean Yes Z H
5. Condition of System:
Good,, system operating properly
. System Pumped
Jason Elliott S7 43
Name Vehicle License umber
Nester and Elliott Services LLC-DBA Jason
Elliott tt "umplin
. Location where contents were disposed-.'
LS ,
31 2 1
engbre of Hauler Date
Signature of Receiving Facility fate
t5forrn4.do -03/06 System Pumping Record Page