HomeMy WebLinkAbout- Septic Pumping Slip - 863 WINTER STREET 1/8/2019 Commonwealth Massachusetts^�[]��OMOO\&����/u / w/ /v/����|���[�^ /U!�~^`"° ��� �������r���
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System Pumping
Record
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Form 4 ��y��0FNORTHANOUVB�
HEAL HDEF��[�EN�
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
|ooe| Board of Health to determine the form they use,The System Pumping Record must be aubmittod to
the local Board ofHealth or other approving authority within 14 days from the pumping dote in
accordance with 31O [|INR15.351.
A, Facility Information
Important:When
filling out fonnn i. System Location:
on the
use only the tab 8B3 Winter Street
key m move your Address
cursor do not
North Andover MA 01845
use the rmm `'''
u
key. ~°''` ``~`~ Zip Code
2. System Owner:
^---~ Adami
Name
Address(if different from location)
State_ Zip Code
978-808-8857
B. Pumping Record
12KK2018 15Gall.00
1. Date o/Pumping 2. Quantity Pumped:
3. Type cfsystem: Fl Cesspool(s) Septic Tank n Tight Tank El Grease Trap
n Other(describe): --
4. Effluent Tee Filter present? Yes No |f yes, was dcleaned? Yee No
5. Condition of System:
Good, t ting properl
G. System Pumped By:
Jason Elliott S71437
Name Vehicle License Number
|v*stnrand Elliott Services LLC-D8AJaaun
Elliott Pumping
7. Location where contents were disposed:
GLGO
112/6/2018
eSi,—.,e of Hauler Date
-Signature of Receiving Facility -bat—e
t5funn4.uoo^03m6 System Pumping Record^Page oore