HomeMy WebLinkAboutSeptic Pumping Slip - 229 Grey St - 10/10/24 - Septic Pumping Slip - 229 GRAY STREET 10/10/2024 Commonwealth �� Massachusetts
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System Pumping
Record
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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
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 14days from the pumping date in
accordance with 31OCK4R15.351.
A, Facility Information
Important:When
filling out mmm 1. System Location:
on the computer,
use only the tab 22A <� ��r��t
key to move your Auomas
cursor'do not
North Andover MA 01845
use the return
key. ~'`,''```'' State Zip Code
2. System Owner:
^---~ Jason Di h i
lNiame-
978-902-3027781-354-9413
Td-ephone Number
B. Pumping Record
1. Date ofPumping 10/10/2024 2� Ou�ndtyPump�d� 1500
Gallons
3. Type ufsystem: Cesspool(s) Septic Tank [l Tight Tank n Grease Trap
El Other(describe):
4. Effluent Tee Filter present? Yea No |f yes, was itcleaned? Yes No
5. Condition ufSystem:
Good, system operating properly
S. System Pumped By:
Jason Elliott S71437 or V85257
|veeter and Elliott Services LLC-DBAJason
Elliott Pumping
7. Location where contents were disposed:
GL8D
1O/1O/2O24
Date
ignature of Receiving Facility Date
oform*.uoo'uoms System Pumping Record^Page 1cx8