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HomeMy WebLinkAbout- Septic Pumping Slip - 2177 SALEM STREET 11/13/2018 Commonwealth of Massachusetts ° ("PE IVE --� City/Town of North Andover WN 13 OV1 _... _ ---- System Pumping Record c NOR ri i AR")OVER Form 4 u li°�i` � ul�ulelwc ilai 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 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer,use only the tab 2177 Salem Street key to move your Address _ _..... cursor-do not _North Andover NIA 01845 use the return -State - -- Cod e key. City/Town Lip 2. System Owner: rib Kyle Worthley Name mnm Address(if different from location) City/1 own State Zip Code 978-960-9063 Telephone Number _.._._,_.........._......................_ ._....._.._...............______..... B. Pumping Record 10/8/2018 1500 1. Date of Pumping _..._..___.__._...._-- 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank © Grease Trap ❑ Other(describe): _ . _.... _.__..._.._____ _....... 4. Effluent Tee Filter present? Yes ® No If yes, was it cleaned? Yes ® No 5. Condition of System: Good, system operating properly 6. System Pumped By: Jason Elliott S71437 .......... ._._._..— Name Vehicle License Number Ivester and Elliott Services LLC-DBA Jason Elliott Pumping 7. Location where contents were disposed: GLSD 10/8/2018 SI ure at'Hauler Date Signature of Receiving Faci6ity Date. t5form4.doc•03/06 System Pumping Record-Page 1 of 13