HomeMy WebLinkAboutSeptic Pumping Slip - 127 OLYMPIC LANE 1/9/2018 |
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Commonwealth of Massachusett
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C'fy/�T{ V ] of North Andover
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System Pumping�� °~ ~"
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 or other approving authority within 14 days from the pumping date in
accordance with 310C[WR15.351.
A~ Fac-U~tyUnformat~on
Important:When
filling out forms i. System Location:
on the computer,
use only the tab Olympic Lane
key mmmve Your *uure,y
cursor-uonot North Andover MA 01845
use�em�m
------
key. 7��r�v��- State Zip Code
2. System Owner:
~---~ AnthonyFesta
Name
ress(if different frorn location)
ity/Town State Zip Code
978-738-9889
B. Pumping Record
12/�/2U17 1S0O
1. Date of Pumping Date Quantity Pumpod�
Gallons
3. Type mfsystem: Cesspool(s) Septic Tank n Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? Yea No |fyes, was dcleaned? Yeo No
S. Condition of System:
Good system |
G. System Pumped By:
Jason Elliott S71437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
Si12/5/2017
Hauler oat*
o|onamreofnoceiv|noraoi|ity Date
mmnn4,uoG'o3/06 System Pumping Record~Page 1or1I