HomeMy WebLinkAbout- Septic Pumping Slip - 456 SUMMER STREET 10/9/2018 �����
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Form 4
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 31OCK8R15.351.
A. Facility Information
| ntaot:vvhun
filling outfo 1. System Location:
on the computer,
use only the tab mm��m�
key to move you, Address
Cursor'«unot North Andover MA O18�5
use�ammm
------
key, mtyTuwn State Zip Code
2 Symtmm Owner:~---~ DonnaCar|mtrom
Name
City/Town State Zip Code
803-533-0084
Tdephone Number
B. Pumping Record
9/6/2018 1�OO
1. Date Of Pumping 2. Quantity Pumped:
(� �� [� �
J� Typaofoyub*m� ^~ Cesspool(s) ~~ Septic �� Tight [ Grease Trap
LJ Other(describe):
4. Effluent Tee Filter present? Yee No |f yes, was i1cleaned? Yes No
5. Condition of System:
Good, system operatingproperly
8. System Pumped By:
Jason Elliott S71437
|veu&er and Elliott Services LLC-DBAJason
' Elliott Pumping
7. Location where contents were disposed:
GL8O