HomeMy WebLinkAboutSeptic Pumping Slip - 25 WINDSOR LANE 6/6/2018 ���
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System Pumping�� _ , , — HEXTHOERARTN5W
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Form 4
DEP has provided this form for use by|muu| Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided hero. Before using this form, check with your
local Board of Health bodetermine the form they use. The System Pumping Record must be submitted to
the |ovm| Board of Health orother approving authority within 14 days from the pumping date in
accordance with 31OCMR 15.351.
A, Facility Information
Important:When
nNinoout forms i. System Location:
onthe computer,
use only the tab 25Windsor Lane
key tomove your Address
ovmnr-do not
NprthAndover MA 01845
use the mm�
xuv. City/Town State Zip Code
2. System Owner:
^----~ TodLebde
Name
ity/Town State Zip Code
617-821-1400
Telephone Number
B. Pumping Record
5/10/2018 1500
1. Date ofPumping Date 2. Quantity Pumped:
3. Type ofsystem: F1 Cesspool(s) 0 Septic Tank Fl Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? Yes No |fyes, was itcleaned? Yea Z No
5. Condition of System:
Gond system dproperly
6. System Pumped By:
Jason Elliott S71437
icle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
5/10/2018
Si ure of Hauler Date
ignature of Receiving Facility Date
mmn14.umu^03/0e System Pumping Record^Page 1ofn