HomeMy WebLinkAbout- Septic Pumping Slip - 67 FOSTER STREET 11/13/2018 ���������
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System Pumping
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Form 4 HEALJ �[)ERARIMEN3
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 |moa| Board of Health or other approving authority within 14 days from the pwmpingdate in
accordance with 318CW1R15.351.
A~ Facility Information
Important:When
filling out forms 1. System Location:
on the
u���u�mh� G7 Foster Street
key m move your Address
r«rs«' do not North Andover &1A 01845
use the return
key. City/Town State Zip Code
2. System Owner:
"---� Matthew Rivet
Name
city/Town State Zip Code
978-273-7852
B. Pumping Record
10/4/2818 2OOO
1. Date of Pumping 1 C>uan1ityPumped.
3. Type ofxyetem: El Cesspool(s) Septic Tank n Tight Tank El Grease Trap
n Other(describe): -----
4. Effluent Tee Filter present? Yes Z No |f yes, was itcleaned? Yes Z No
b. Condition of System:
Good, t ti |
6. System Pumped By:
Jason Elliott 871437
Vehicle License Number
|vemterand Elliott Services LLC-DQAJuuun
Elliott Pumping
l Location where contents were disposed:
8LSO