HomeMy WebLinkAbout- Septic Pumping Slip - 486 SHARPNERS POND ROAD 9/7/2018 � �
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C[)mUloMyyea|fh of Massachusetts ')
C^fx/T] Vl of North Andover JVer J'100A,01
System Pumping Record
Form 4
DEP has provided this form for use by local 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
|000| Board of Health to determine the form they use. The System Pumping Record must basubmitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCyNR15351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 48GSho ar Pond Road
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key mmove your pmomao
n«o«' do not North AndovmrMA 01845
use the return Code
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2. System Owner:
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Name
Address(if different from location)
ityTrown
B. Pumping Record
1. Date of Pumping 8/1/2018 2� Quantity Pumped: 1500
DateGallons
3. Type ufsystem: El Cesspool(s) Septic Tank Tight Tank Grease Trap
F] Other(describe):
4. Effluent Tee Filter present? Yea No |fyes,was itcleaned? Yon No
b. Condition of System:
Good, system operatingproperly
6. System Pumped By:
Jason Elliott S71437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
.Elliott Pumping
7. Location where contents were disposed:
GLSD
es6re, of Hauler Date
8M/2O18