HomeMy WebLinkAbout- Septic Pumping Slip - 10 CHERISE CIRCLE 11/13/2018 Commonwealth nfMassachusetts
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System Pumping Record TOWN QFWOI�T ANDOVER
Form 4
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 her*. Before using this form, check with your
|oom| Board of Health h)determine the form they use. The Gyu1nm Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 daynfrom the pumping doha in
accordance with 31OCyNR15.351.
A, Facility Information
Important:When
nU I. System Location:
on the computer, 1OChednuQrdm
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key w move Your xuunmy
cursor do not
North Andover MA 01845
use the return
key. City/Town ~'~`` Zip Code
2. SystemOwner:~---�' Jeff Melville
Address(if different from location)
City/Town State Zip Code
617-216-1439
Telephone Number
B. Pumping Record
1085/2018 1300
i. Date ufPumping 2. Quantity Pumped. Gallons
3. Type ofsystem: El Cesspool(s) 0 Septic Tank Fl Tight Tank F1 Grease Trap
E] Other(describe):
4. Effluent Tee Filter present? Yes No |f yes,was itcleaned? Yes No
5. Condition of System:
Good system bproperly
8. System Pumped By:
Jason Elliott S71437
Name Vehicle License Number
|vestorand Elliott Services LLC-D8AJa000
Elliott Pumping
7. Location where contents were disposed:
GLSD