HomeMy WebLinkAboutSeptic Pumping Slip - 66 STERLING LANE 6/6/2018 ����������
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ICI
Commonwealth of Massachusetts ]UW 0 5
City/Town
'ty/ O & l of North And
oVer ANO(WEIR,
V- 0 System Pumping Record ����"4' ��
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must besubstantially 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 datein
accordance with 31UCK4Fl15.351 ------------.
A, Facility Information
Important:When
filling out forms 1. System Location:
� moncomputer, 66 Sterling Lane
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key mmove your Address
cursor-u«m« North Andover MA 01845'5600
use�ou$um
key, ~,''`~^ State— Zip Code
2. System Owner:
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David Winwvi ht
-Adar"e".ss- ("if different-from location)
,ity[Town State Zip Code
617-818-4159
B. Pumping Record
5/22/20181500
1. DoVy of Pumping 2. Quantity Pumped:
Gallons
3. Type ofsystem: [l Cesspool(s) Z Septic Tank E] Tight Tank El Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? Yes Z No Uyes, was itcleaned? Yea Z No
5. Condition ofSystem:
Heavy solidsoften. �� d bproperly
6. System Pumped By:
Jason Elliott S71437
.Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pm i
7. Location where contents were disposed:
GL8D