HomeMy WebLinkAbout- Septic Pumping Slip - 8 EVERGREEN DRIVE 11/13/2018 Commonwealth nfMassachusetts
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City/Town of North /\[ldOyer �0k ƒ 3 A/�
System Pumping Record 70NVN OF
Form 4 �~~~~^n —`
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 318C[NR16.351.
A~ Facility Information
Important:
filling out forms 1. System Location:
on the computer,
8
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key m move your Address
cursor-do not
North Andover MA 01845-6002
use the return
key. ~�'....^ State Zip Code
3. System Owner:
~---� K4iohao| Kinhinevak
Name
Address(if different from location)
City/Town State Zip Code
978-883-2187908-557'3842
B. Pumping Record
10/31/1018 i50O
1� Date of Pumping 2. Quantity Pumped:
3. Type ofsystem: El Cesspool(s) 0 Septic Tank F-1 Tight Tank F Grease Trap
El Other(describe): -----____
4. Effluent Tee Filter present? Yea No |f yes, was itcleaned? Yes Z No
5. Condition of System:
Good system ti |
S. System Pumped By:
Jason Elliott S71437
Name Vehicle License Nurni3eT-'-'-"
|voster and Elliott Services LLC-OBAJason
Elliott Pumping
7. Location where contents were disposed:
GLSO
10/31/2018
WSi of Flauler" D.ate
ignature of Receiving Facility Date
,emnn4.uvo^03/06 System Pumping Record^Page 1o(13