HomeMy WebLinkAbout- Septic Pumping Slip - 855 WINTER STREET 6/4/2019 Commonwealth of Ma
City/Town o North; Andover
System Pumpf"Ing Record
Form
, n r
EP has provided this form for use by local Boards of Health. Other forms s may be used, but the
information must be substantially the same as that provided bare.. Befor sing this form, check with your
local Board of Health to,determine the fora they use. The System Pumping Record must be submitted t
the local Board off-lealth or other approving uth rit within 14 days from the pumping date in j
accoIrdance with 31 CMR 1 N3 'I.,
A. Facility
Important:When,
filling out forms I., System Location:
on the r Uter„
use only the t , et
Ivey to move your~
cursor-do not North Andover MA 018,45,
use the return, City/Town State Zip,Code
f
System Owner: 1
Karen Mawn
p' Name
am
Address If different frorn location)
City/Town Stag dip Code
-3 7- 2 02
T Ia h-o'—ne I' umber
,B. Pumping Record
52 0 191 15,00
1.. Cate of Pumping 2. Quantity lumped ..u. ...m.. ..�.._
Cat Gallons
3. Type of set a: Ej C s ](s) Z Septic Task Tight Tank r+ s Trap
0 Other(describe): ,
. Efflu rat Tee Filter resent Yes No If yes,,was it cleaned Z Yes, ' H
5. Condition of System:
:
Good, systern operatingproperly
16. System Pumped .
Jason Elliott S71 3 7
lar rVehicle License Number
I est r and Elliott Services LLC-DBA Jason
Elliott a !Iru
''. Location where contents were dispose:
ILS
51 12019
S1 aura of Hagler IDaf I
Signature of Receiving Facility Date
t5form, 4. o •03106 System Pumping Record,,Page 2 of 8,