HomeMy WebLinkAbout- Septic Pumping Slip - 83 PENNI LANE 6/4/2019 LN Commonwealth of Massachusetts
City/Town NorthAndover
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System, Pumping Record
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Fortet
DEP has provided this form for use by local Boards of alt . Other forms may used, but the
information rust be substantially the same as that provided here. Before using this f rr , check with your
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local Board of Health to determine the forma they use. The System Pumping Recoird must be submitted't
the local Board'of Health r other approving authority within 14 days from the pumping date in
accordanice,with 310,CIVIR 15.351.
A. Facility Informati,on
Important:When
filling Out forms 1. System, Location:
on the computer,;
use only the tab 83 Penril Leas
key to move your Address
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cursor-do n t North Andover ........... �� 1 5
use the u� twrr� City/Town Stake Zip Code
cl2. System Owner.-
Mike Fritzing r
erne
Address(if different from location"
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Cit (Town State dip Code
m
Telephone Number
B. PumpingReclord
�P 5/8 L w 5
1. Date of Pumping �.... 1-1 ntit Pumpe :
Ctat 00
Gallons
3. Type of system, Cesspool(s) 0 Septic Tank El Tight Teak. El Grease Troup
Other asrier „.m. , .... ... .,m.....m mm m. mm... . ......
Effluent Tee Filter present? Yes No If yes, was, it cleans Yes No
5. Condition of System:
Gaol, system operating properly
6. System PumpedBy.-
Jason Elliott S 1 "
Dame Vehicle License urrb r
I ast r and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location whe!re contents were disposed:
GLS
5 ,2 1
�i urn f I I r Date
ignature of Receiving Facility Date
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t,f rm, ,d *03106 System Purnping Record Fags 1 of