HomeMy WebLinkAbout- Septic Pumping Slip - 61 WHITE BIRCH LANE 11/13/2018 ����m� � �
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System Pumping-� Record HEAUMDU"A9,VAGWT
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 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 |oom| Board of Health ur other approving authority within 14 days from the pumping date in
accordance with 310CPNR15.361.
A, Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 81 White Birch Lane
key m move Your *oumnv
cursor'««not North Andover MA 10845-1112
use the return
key, City/Town State Zip Code
2. System Owner:
^---� Todd8|o
per
Name
City/Town State Zip Code
978-655-4740
Telephone Number
B. Pumping Record
1O��2Oi8 15OO
1. Date of Pumping 2� Qu�ndtyPwm�ed�
allons
��
3. Type mfsystem: ^� Cesspool(s) .��~ Septic Tank ��l~ Tight Tank ^[�
� Grease Trap
LJ Other(describe):
4. Effluent Tee Filter present? Yam No |f yes, was itcleaned? Yes No
5. Condition of System:
Good, system operatingproperly
O. System Pumped By:
Jason Elliott 871437
arne Vehicle License Number
|veeter and Elliott Services LLC-QBAJason
Elliott P i
7. Location where contents were disposed:
GL@D