HomeMy WebLinkAboutSeptic Pumping Slip - 345 Berry - 10/28/24 - Septic Pumping Slip - 345 BERRY STREET 10/28/2024 Commonwealth �� K� � �+��
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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 |ooe| Board of Health Vr other approving authority Within 14 days from the pumping date in
accordance with 31OCIVIR15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 345 Berry Street
xeym move your Address
cursor'do not
North Andover ��A 01845
use the�tum
key. ~'`,''~`~' State Zip Code
2. System Owner:
~---~ O'Connell
Namo ress(if different from location)
-
ity/Town State Zip Code
351-2O1-1035
Telephone wvm*:r
B. Pump^ng Record
1. Oeh* of Pumping 10/28/2024 2� Quantity Pumped: 1500
Gallons
3. Type ofsystem: Cesspool(s) Septic Tank n Tight Tank F] Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? Yea No |f yes, was itcleaned? Yes No
6. Condition of System:
Good, ha ratiproperly
G. System Pumped By:
Jason Elliott S71437orV86257
|veater and Elliott Services LLC-DBAJason
Elliott Pumping
7. Location where contents were disposed:
GLSD
10/28/2024
-e,-S � Hauler- Date- -- --
ignature of Receiving Facility Date
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