HomeMy WebLinkAboutSeptic Pumping Slip - 134 OLYMPIC LANE 11/17/2017 ����������
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System Pumping Record ��DFMO�A��E
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HEAODHDEPAR �EM�
Form 4
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
|moa| 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 ill
accordance with 3i0C[NRib.3b1.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the mmun��ewh� 134 Olympic Lane
meymmove your Address
*um« mumu North Andover MA81845
use the return
—'.
Cityfl-own State Zip Code
2. System Owner:
"---`
Theresa Hardy
Name
ess(if different from location)
Ity own State Zip Code
978-258-9608
B. Pumping Record
10/24/2017 1500
1. Date of Pumping Date 2. Quantity Pumped. Gallons
3. Type ofsystem: El Cesspool(s) 0 Septic Tank Fl Tight Tank El Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? Yes Z No |fyes, was itcleaned? Yea Z No
5. Condition of System:
Good, system operating |
0. System Pumped By:
Jason Elliott S71437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pum in
7. Location where contents were disposed:
GLSD
10/24/2017
-es'g .�of Hauler Date
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