HomeMy WebLinkAbout- Septic Pumping Slip - 263 RALEIGH TAVERN LANE 1/8/2019 /
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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
|uua| Board of Health to determine the form they use. The System Pumping Hncnnd must be submitted to
the |orn| Board of Health or other approving authority within 14daym from the pumping date in
accordance with 310 CK8R 15.351.
A, Fac~U~tyUnformat^oKU
Important:When
filling out forms 1� System Location:
on the computer, | La
v�m�wot� uonu
key m move your Address
cursor'do not
North Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
"---� [NoN|ohVU
Name
6A Address.(-if..d i if I e.r I e-n-t-f 11 r 11 o-m location)
State Zip Code
078-MQ1-1072
fewphvnemumo°,
B. Pumping Record
12/-7C2O1O 1580
1. Date of Pumping 2. Quantity Pumped:
Gallons
3. Type ufsystem: Cesspool(s) Septic Tank Fl Tight Tank Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? Yea No |f yes, was itcleaned? Yes No
5. Condition of System:
Good, iproperly
8. System Pumped By:
Jason Elliott S71437
Narne Vehicle License Number
|vuster and Elliott Services LLC-UBAJason
Elliott Pumping
7. Location where contents were disposed:
GLSO