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HomeMy WebLinkAbout- Septic Pumping Slip - 24 CARLTON LANE 10/9/2018 Commonwealth of Massachusetts ff = � - w City/Town of North Andover ("')C " 0 9 2( System Pumping Record a y �' 'g ����i"��`�,r t.�i I ir�hi I I I M II)(ivi;i�Mw Form 4 IGi.'i Lali iLl'1�,Cz"f f�°�f�l''! 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 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab 24 Carlton Lane key to move your Address _......... cursor-do not North Andover MA 01845-5603 use the return _ __. ...... ....._._ key. City[f own State Zip Code 2, System Owner: Sarah Tower Narne rruem __..__......_ ..... .............._ ... _........ ... Address(if different ..._....._..erent.from location) __, _......._.... ........... C[tylT _.._ .............__.__ _._._.._.__... .._..._........ own State Zip Code 978-807-7202 Telephone Number ----------------- .._............._.....__-........._..............-...--- ---,,,.. _.._.. .._.._._..._.....m................._._..._......m......._._._._..._..__.__ B. Pumping Record 1. Date of Pumping 9/27/2018 2. Quantity Pumped: 1500 Date Gallons 3. Type of system: © Cesspool(s) ® Septic Tank ❑ Tight Tank Cf Grease Trap ❑ Other(describe): _.__....._.___._.__.._____.__...___ _. ...._......_.. 4. Effluent Tee Filter present? Yes ® No If yes,was it cleaned? Yes ® No 5. Condition of System: Good, system operating properly 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 .. .... .................... ... i 9/27/2018 Si uro of Wauler Date 1 Signature of Receiving Facility Date t5form4.doc•03106 System Pumping Record•Page 1 of 14