HomeMy WebLinkAbout- Septic Pumping Slip - 45 WINDKIST FARM ROAD 5/2/2019 RECE!
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Common l Massa use i iii� "d
City/Town North Andover
System Pumpig Record
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Form 4 r 4
L 111N,
DEFT has provided this form for,use local Boards of Health. Other forms, may be used, but the
informiation rust be substantially the same as that provided here. Before using thisform, check with your
local Board of Health to determine the,form they use. The System Pump�ing Record must be,submitted t
the local Board of Health r other approving authority within 14 days from the pumping date in
accordancewith ,310 CAR 15.3151.
A Facility I mao
Important:When
filling out forms 1. System Location-
on the om ut r,
use nl t t l !5 Wmm dl ist Farm oaf'
key to move your Address
cursor-do,notNorth Andover MA 01845
use the return
key, City/Town Ot t dip Code
,. System Owner-
ta
Stephen Gaeta
Nam
teun
cif different from location)
bit flow n State Zips Cade
78 - - 2 3
...........................
Telephone Number
Bi, itPumping Record
1. Date of Pumping �,..... .m� 2. Quantity Pumped: 1500
Gallons
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3. Type system:m m: Cesspool(s) Septic Tank Tight Tank Grease 'rap
Other(descr'be):
4. Effluent Tea Filter present? Yes No If'yes, was it cl anied Yes No
5. Condition System:
Good, system operating properly
1
t
. Slyst+ m Pumped y:
Jason, Elliott S7 31 '
Name Vehicle License Number
Nester and Elliott,services L,LC-DBA Jason
lli tt Pumping
7. Location Dare contents were disposed.
G LS C
21 r
eSig, uref Hauler Date
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Signature f Receiving Facility Groat
t5f rr .d ,,03/06 System Pumping Record Page I f'
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