HomeMy WebLinkAboutSeptic Pumping Slip - 10 Old Cart Way - 10/24/24 - Septic Pumping Slip - 10 OLD CART WAY 10/24/2024 Commonwealth Massachusetts
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System Pumping Record
Form 4
DEP has provided this form for use by|oom| Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Bafnna using this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must bmsubmitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCMH15.35l.
A~ Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
O0�e �o�
u�m�met� / Way
key to move your Address
cursor-do not
North Andover MA 01845
use mem�m
key. City/Town ~a^~ Zip Code
2. System Owner
~---� Amneu1TaUa
-6fy own -State Zip Code
972-782-8027
Telephone Number
B. Pumping Record
1OC�/2O24 1GOO
1. Date of Pumping 2 Quantity Pumped:
ns
3. Type ofsystem: Cesspool(s) Septic Tank Tight Tank R Grease Trap
LJ Other(describe): ---
4. Effluent Tee Filter present? Yea No |f yes, was itcleaned? Yes No
5. Condition of System:
Good system hproperly
G. System Pumped By:
Jason Elliott �71437orV85257
ame Vehicle License Number
|veabar and Elliott Services LLC-DBAJason
Elliott Pumping
7. Location where contents were disposed:
GLSO