HomeMy WebLinkAbout- Septic Pumping Slip - 51 WELLINGTON WAY 1/8/2019 �
��(]Dl0O[]DVVe�3|fh of K8asS��(�hUsefkz RECEIVED
��' nfyJ �� �n�
��|IV/ | [�8/[l ��/ North/ Andover
��xx��u� Pumping ��v �x�
����u��� x����u�u
TOW1 UfNDR HANDOVE
Form 4 H�A[ HDB9\RT�E�7
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 us 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 mr other approving authority within 14 days from the pumping date in
accordance with 318CK4Ri5.351.
A, Facility Information
Important:When
filling out h,nmv 1. System Location:
on the use me�m� S1 Wellington VV
key mmove your Address
cursor do not
North,Andover [WA U1845
use�en*um
key. City/Town State Zip Code
2. System Owner:
~---~ Anna A|iberti
Name
State Zip Code
878-482-6547
Telephone Number
B. Pumping Record
12/21/2018 15OO
1. Date ofPumping 2. QuandtyPumped. Gal.
3. Type ufsystem: [l Cesspool(s) 0 Septic Tank El Tight Tank El Grease Trap
E] Other(describe):
4. Effluent Tee Filter present? Yes Z No |f yes, was itcleaned? Yes M No
6. Condition of System:
Good, system operatingproperly
G. System Pumped By:
Jason Elliott S71437
Name Vehicle License Number
|vaeb*r and Elliott Services LLC-DBAJason
Elliott Pumping
7. Location where contents were disposed:
GLSD