HomeMy WebLinkAboutSeptic Pumping Slip - 417 RALEIGH TAVERN LANE 10/17/2017Commonwealth nfMassachusetts
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Form 4
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DO"AWMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, 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 o,other approving authority within 14days from the pumping data in
accordance with 31OC[NR15.351.
A,Facility Information
Important: When
filling out forms 1System Location:
on the computer,
use only the tab 417 RaleighTavern Lane
key * move your Aomwx
cursor do not
North Andover
use the return
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2. System Owner:
DonnaShuNnff
mame-------
Address (if different from location)
oitynow^
nmm Zip Code
803~479'4428
Telephone Number
B.Pump^ng Record
Q/28/�017 15UO
1 Date ofPumping 2Quantity --Gallons
3, Type of system: n Cesspool(s) 13 Septic Tank El Tight Tank n Grease Trap
D Other (describe):
4. Effluent Tee Filter present? Yes 04 N o If yes, was it cleaned? Yes 0 No
5. Condition cfSystem:
Good, system operating properly
8. System Pumped By:
Jason Elliott
Name
|vesterand Elliott Services LLC-OBAJason
Elliott Pumping
7. Location where contents were disposed:
GLSD
Vehicle License Number
A/2Q/2O17
ure of Hauler Date
Signature mReceiving Facility Date
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