HomeMy WebLinkAboutSeptic Pumping Slip - 93 RALEIGH TAVERN LANE 11/17/2017 �
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Commonwealth
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WOV 1 � ?O17
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System Pumping�� " " ~= HEALrH DEpARTMEM'
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
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health orother approving authority within 14days from the pumping date in
accordance with 310CMR 15.3S1.
A. Facility Information
Important:When
filling out forms 1. System Location,
on the computer,
use only the tau 93Raleigh Tavern Lane
key wmove your xuumxu
cursor-do not
North Andover MA 01845-5625
use the return
key. ~'^''~~'' ^`"= Z''°"""
2. System Owner:
~---~
Kurt Von 8neidmrn
Name
078`208-1107
elephone Number
B. Pumping Record
10/3/2817 1500
i. Ooha of Pumping bate 2. Quantity Pumped. Gallons
3. Type ofsystem: F-1 Cesspool(s) 0 Septic Tank Fl Tight Tank F-1 Grease Trap,
Lj Other(describe): -
4. Effluent Tee Filter present? Yes No |fyes, was itcleaned? Yes No
5. Condition ofSystem:
Good, system d |
6. System Pumped By:
Jason Elliott 871487
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
10/3/2017
1�gure of Hauler Date
t5fom4.ovc-03m6 System Pumping Record^Page 2"f11