HomeMy WebLinkAboutSeptic Pumping Slip - 291 WINTER STREET 10/17/2017Important: When
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Commonwealth nfMassachusetts
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System Pumping
Record
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Form 4
DEPhas provided this form for use bylocal Boards ofHealth. Other forms may beused, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCMR1S.3S1.
A Facility Information
1. System Location:
291 Winter Street
Address
North Andover
2. System Owner:
Kevin McGregor
01845
Address (if different from location)
City/Town
State
078-683-0452
Telephone Number
B'Pump'ng Record
1. Date of Pumping
0M/2O17
3. Type of system: F-1 Cesspool(s) ��Septic Tank Flight Tank [lGrease Trap
0 Other (describe):
4. Effluent Tee Filter present? Yee 0 No |fyes, was itcleaned? Yea US No
5. Condition ofSystem:
Good, system operating properly
0. System Pumped By:
Jason Elliott
Name
Ivester and Elliott Services LLC-DBAJason
Elliott Pumping
7. Location where contents were disposed:
GLSO
Vehicle License Number
S@M'Mure of Hauler
Signature of*ecelvingFacility
9/1/2U17
mmmw.dou ooms System Pumping Record ^ Page 1mo