HomeMy WebLinkAboutSeptic Pumping Slip - 498 SALEM STREET 8/6/2018 �������
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Commonwealth
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AM(I� 0 62,018
rp City/Town of North Andover
System Pumping
Record T��W�FND�THAN�����
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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 authat 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 |o*e| Board of Health orother approving authority within 14days from the pumping date in
accordance with 31OCMR i5351.
A, Facility Information
Important:When
filling Out forms i. System Location:
on the weonh�e�b� 498Salem Street
key mmove your Address
cursor-do not
North Andover MA 81845
use the return
key. City/Town State Zip Code
2. System Owner
�---" Jake Donovan
Name
tirf6wn— State Zip Code
603-548-8574
Telephone Number
B. Pumping Record
7/25/2018 1500
1. Date o[Pumping2Date � Quantity Pumped:
Gallons
3. Type ofnystem: FlCesspool(s) Septic Tank Tight Tank Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? Yes No |fyes, was itcleaned? Yes No
5. Condition nfSystem:
Good, system operatingproperly
6. System Pumped By:
Jason Elliott S71437
--I�Wrne— Vehicle License Number
|weoharand Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
E)LSD �
7/25/2018
'ig ure of Hauler Date
"m'a="°'Receiving Facility ~~e
wfonn4.dv, 03m6 System Pumping Record^Puoa o mo
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