HomeMy WebLinkAbout- Septic Pumping Slip - 926 FOREST STREET 10/9/2018 7���������
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Commonwealth nfK8 Massachusetts
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System Pumping
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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 be substantially the same as that provided here. Before using this form, check with your
local Board of Health todetermine the form they use. The System Pumping Record must bosubmitted to
the local Board of Health or other approving authority within i4 days from the pumping du(w in
accordance with 310CMR15.3S1.
A, Facility Information
Important:When
filling out forms 1. System Location:
on the
pmonh�emh� 926Forea Street
key m move your Address
cursor do not
North Andover MA 0iO45-3324
use the e*um
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2. System (Jwmmc
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State Zip Code
B. Pumping Record
I. Date nfPumping 9/20/2018 2. C)uandtyPumpod: 1008
DateGallons
3. Type ofsystem: Cesspool(s) Z Septic Tank F Tight Tank El Grease Trap
[� Other(describe):
4. Effluent Tee Filter present? Yes No |f yes, was |tcleaned? Yen Z No
5. Condition of System:
Good system Uproperly
6. System Pumped By:
Jason Elliott Q71437
Name Vehicle License Number
|vaotar and Elliott Services LLC-DBAJason
Elliott Pumping
7. Location where contents were disposed:
(5LSO