HomeMy WebLinkAboutSeptic Pumping Slip - 85 OGUNQUIT ROAD 5/7/2018 Commonwealth �� K�Massachusetts RECEIVED
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City/Town of North Andover MAY 0 7 201b
System Pumping ��� ��|
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Form 4 HEP'UM DUARI'MEmT
DEP has provided this form for use by|ouu| 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 Uodetermine the form they use. The System Pumping Record must be submitted to
the ]oou| Board of Health orother approving authority within 14days from the pumping date in
accordance with 31OCIVIR15.351.
A, Facility Information
Important:When
fiN ng out forms 1. System Location:
on the computer,
key to move your Address
cursor'«vnot North Andover MA 01845-147O
use the return
hey. ~`'`~^ State Zip Code
2. System Owner:
~---^ Reger
Name
Address(if different from location)
City[Town State Zip Code
401-559-3484
Telephone Number
B. Pumping Record
01/20/2018 1500
1. Date ofPumpinQ 2. Quantity Pumped. Gallons
3. Type ofsystem: El Cesspool(s) Septic Tank Fl Tight Tank El Grease Trap
L] Other(describe):
4. Effluent Tee Filter present? Yeo No |fyes,was itcleaned? Yea No
5. Condition of System:
Good, i d
G. System Pumped By:
Jason Elliott 871437
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSO