HomeMy WebLinkAbout- Septic Pumping Slip - 49 WINDSOR LANE 10/9/2018 Commonwealth Massachusetts ���������
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Record ~`' ~ ~ -'
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Form 4 \mwm
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OEP 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 318CK4R1G.351.
A~ Facility Information
Important:When
filling out mpnv i. System Location:
on the
�eon�me�h� 4Q Windsor Lane
key m move your audmuo
mmpr do not
North Andover MA 01845
use the return
key. ~'^'^'`'— State Zip Code
2. System Owner:
~---� KannethVeMuUo
Address(if different from
City/Town State Zip Code
017-438-6800
Telephone Number
B. Pump~ng Record
Q/i3/2Ui0 15O0
I. Dmba of Pumping 2� Quantity Pumped:
Gallons
3. Type ofsystem: El Cesspool(s) Septic Tank Tight Tank El Grease Trap
L� Other(describe):
4, Effluent Tee Filter present? Yes No |f yes, was iicleaned? Yes No
5. Condition ofSystem:
Good, system operatingproperly
6. System Pumped By:
Jason Elliott S71437
Name Vehicle License Number
|vaster and Elliott Services LLC-DBAJason
Elliott Pumping
7. Location where contents were disposed:
GLSO