HomeMy WebLinkAboutSeptic Pumping Slip - 163 OLYMPIC LANE 1/9/2018 Commonwealth
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C.f«/TC)VyD of North Andover
System Pumping Record
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Form 4 H�A1U|DLR\RO4LN�
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 doha in
accordance with 31OCIWR15.351.
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A. Facility Information
Important:When
filling out forms 1. System Location:
on the�eon��emu� 63 Olympic Lane
key tomove your Aumnx
cursor do not
North Andover MA 01845
use the return
xvv. City/Town— State— —' ---
2. System Owner
"---� Kathryn S cndo
Name
617'894'7483
Telephone Number
B. Pumping Record
11/30/2017 1500
1. Date ofPumping 2. Quantity Pumped:
Gallons
3. Type ofsystem: �Fl� Cesspool(s) .[�. Septic Tank �[�~ Tight Tank �[�
� Grease Trap
R Other(describe):
4. Effluent Tee Filter present? Yea No |fyes, was itcleaned? Yes Z No
5. Condition of System:
Good, system operatingproperly
O. System Pumped By:
Jason Elliott S71437
Name hicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
8LSD '