HomeMy WebLinkAbout- Septic Pumping Slip - 3 WINTERGREEN DRIVE 10/9/2018 /
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System Pumping — HEALTHDE9AF���EN\
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
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 31OC[NR15.351.
A, Facility Information
Important:When
fi Ili ng m4honnn i. System Location:
on the�evn��emb� 3 Wintergreen Drive
key m move Your odumna
cursor'u»not North Andover MA 01845-1454
use the return
key. City/Town State Zip Code
2. System Owner:
�--� ThmmaaJodka
Name
"bhyffown State Zip Code
978-764-5842
B. Pumping Record
1. Date ofPumping 0/11/2018 1 Quantity Pumped: 1508
Date Gallons
3. Type ofsystem: El Oeaapuu|(u) E Septic Tank F] Tight Tank [l Grease Trap
E] Other(describe):
4. Effluent Tee Filter present? Yea No |f yes, was |tcleaned? Yee No
5. Condition ofSystem:
Good, system radiproperly
0. System Pumped By:
Jason Elliott S71437
Vehicle License Number
Name
|veeter and Elliott Services LLC-DBAJason
Elliott Pumping
7. Location where contents were disposed:
8LSD
9/11/2018
-e- e of Hauler Date
Signature of Receiving Facility Date
x5fumo4.uou'03m6 System Pumping Record~paua 1 v(14