HomeMy WebLinkAboutSeptic Pumping Slip - 2001 SALEM STREET 1/9/2018 �
Commonwealth Massachusetts
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00 ���00�~� Record
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H�ALTHUEPAR|�ENT
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 ommm as that provided hens. 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 |moa| Board of Health orother approving authority within 14days from the pumping date in
accordance with 318 CIVIR 15.351.
A. Facility Information
Important:when
filling out forms 1. System Location:
on the
computer,
use only the tab 200iSalem Street
key mmove your xuoeso
»vm»r do not NodhAndoverMA 01845
use the return
xev. City/Town State Zip Code
2. System Owner:
�---" Erin Blanchard
Name
Address(if different ocation)
City/Town State Zip code
802-318-5715
Telephone Number
B. Pumping Record '
11/28/2017 1500
1. Date of Pumping 2. Quantity Pumped. Gallons
F-1 [�
3. Type ofsystem: ^~ Cesspool(s) �y�~ Septic Tank �0� Tight Tank �� Grease Trap
R Other(describe):
4. Effluent Tee Filter present? Yes No |fyes, was itcleaned? Yea 0 No
5. Condition ofSystem:
Good, system operatingproperly
G. System Pumped By:
Jason Elliott 871437
Vehicle License Number
Nester and Elliott Services LLC-DBA Jason
Elliott Pumping
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7. Location where contents were disposed:
GLSO