HomeMy WebLinkAbout- Septic Pumping Slip - 18 LACY STREET 6/17/2019 i
Commonwealth
RECEIVED
City/Town of NORTH ANDOVER
System Pumping Record
Foam E
T O N� 0'N 0 11 P )OV
DEP has provided this form for use by local al Boards of Health., Other forms may be used, but the
information must be substantially thef same as that provided ere* Be-fore using this fora, check with your
local Board,of Health to determine the form they use., The System Pumping Record rust be submitted t
the local Board of Health r other approving authority within 14 days from the pumping date i
accordancewith 310 CMR 15.�3,51.
A. Facility Information
Important:When
fillinig out forms System Location:
on the computer, L ��'
use only the to
key to moveyour Address
curusesor- not l O T N VE A01845
the return .,. µ .... ...,.,, ., .�,,.. ...rAm....�
it town State Zip Code
2. System Owner.
RI E WALLEY
me
Address if different from location)
City/Town State Zip Code
Telephone Dumber
B. Pumping Record
1. Cute of " min6/13/19 . Quantity Pumped*
It 1500�b i�m ..... mmmm... ..
3. Component: [:1 Cesspool(s) Z Septic Tank El Fight Teak ® Grease Trap
Other(describe)- .. . -.. mm .
w Effluent Tee Filter,present? Yes No If yes, was it cleaned Yes N
5. Observed condition of component pumped:
GOOD
6. System m Pumped y
JAY CURRIER 1 79 6
Name Vehicle License,Number
XS SEPTIC RAII
Company
. Location where contents were disposed:
GLSID
u'l
Date
00/
�I n t r + f Receiving Facilit r attach facility receipt) Date
t5forrn , o 11/12 System Pumping Record o Page 1 of 1