HomeMy WebLinkAboutSeptic Pumping Slip - 45 LACY STREET 10/17/2017Important: When
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19
Commonwealth of Massachusetts
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System Pumping
Record
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Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must basubstantially the same aathat 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 310CK4R15.351.
A.Facility Information
1. System Location:
45 Lacy Street
Address
North Andover
2, System Owner:
[Wiohao| Hale
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B.Pump^ng Record
1. Date of Pumping
9/7/20
Date
7 - . . . . 1500
2. Quantity Pumped:
3. Type ofsystem: El Cesspool(s)
��
�~ Other (describe):
4. Effluent Tee Filter present?
5. Condition nfSystem:
Good, moporaUpr n0000r�
6. System Pumped By:
Jason Elliott
Septic Tank F Tight Tank F-1 Grease Trap
Yes F0 N o, If yes, was it cleaned? Yes 00 No
Name
|vesterand Elliott Services LLC'OBAJason
Elliott Pumping
7. Location where contents were disposed:
GLSD
Signature ofReceiving Facility
Vehicle License Number
9/712017
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