HomeMy WebLinkAboutSeptic Pumping Slip - 35 EVERGREEN DRIVE 8/6/2018 �������
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City/Town of North uoVe[ '�—
System Pumping Record -EAV OGPAr�TMB/
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Form 4
DEP has provided this form for use by local Boards of Health. Other forms may beused, but the
information must be substantially 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 date in
accordance with 310C[NR15.35i.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 35 �v*
mmm�Vmmb ��
key to move your audraw
cursor'ovnot North Andover MA 01845
use the return
key ~°''`~~ ~^~^` Zip Code
2. System Owner:
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Name
ress(if different from location)
State Zip Code
A78-37�-8777
B. Pumping Record
7/18/2818 1500
1. Date of Pumping Date 2. Quantity Pumped:
3. Type ofsystem: F-1 Cesspool(s) E Septic Tank [l Tight Tank Fl Grease Trap
LJ Other(describe):
4. Effluent Tee Filter present? Yes No |fyes, was itcleaned? Yes No
5. Condition ofSystem:
Good, system operating properly
6. System Pumped By:
Jason S71437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pum i
7. Location where contents were disposed:
GLSD