HomeMy WebLinkAbout- Septic Pumping Slip - 50 DUNCAN DRIVE 11/13/2018 Commonwealth �� K�Massachusetts��(��1DO(�D\�����/w / .�/ 'x/��|�����(�/ /[J!�^^`^� �������N���"��-���°�m~��
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Record N�k
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System n- *v
Form 4 TOWN OF N0RTH
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 h*ra. Before using this fonn, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board mf Health or other uppvovin0authohtywidhin14dayahnmthmpumpingdatein
accordance with 31OC[NR15.85i.
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A, Facility Information
Important:When
filling 1. SystemnLmoaUon:
on the�eun�memh� 5O Duncan Drive
key mmove your Address
cursor do not North Andover MA 01845
use the return
k^y. ~'^'''~~^ State Zip Code
2 System Owner:
�—� Technologies LLC
Name
Address(if different from location)
CityfTown State Zip Code
978-810-5146
Telephone Number
B. Pumping Record
I. Date ofPumping 10M6/-018 2� Uu�ntityPumped� 1500
DateGallons
Fl
3. Type of system: �~ Cesspool(s) �|�� Septic Tank �Fl~ Tight Tank ^[�
~ Grease Trap
L1 Other(describe):
4. Effluent Tee Filter present? Yes No K yes, was itcleaned? Yes No
5. Condition cfSystem:
Good, system operatingproperly
6. System Pumped By:
Jason Elliott S71437
|vmatmr and Elliott Services LLC-DBAJason
Elliott Punm in
7. Location where contents were disposed:
GL8D