HomeMy WebLinkAboutSeptic Pumping Slip - 115 Sherwood - 10/3/24 - Septic Pumping Slip - 115 SHERWOOD DRIVE 10/3/2024 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 14 days from the pumping dote in
accordance with 310CK8R15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 115 Sherwood Drive
kevto move your Address
ovmu, do not
North Andover MA 01845
use the return
key. ~`'''~-' --- —'---
2. System Owner:
~--~ JoelSimea
Name
Address(if different from location)
978-420-8418
-telephone Number
B. Pumping Record
18/3/2024 1500
1. Date ufPumping 2. Quantity Pumped:
3. Type ofsystem: [l Cesspool(s) E Septic Tank [l Tight Tank Grease Trap
L| Other(describe):
4. Effluent Tee Filter present? Yes No |f yes, was itcleaned? Yea 0 No
5. Condition of System:
Good, system dproperly
6. System Pumped By:
Jason Elliott S71437orV862�7
Name Vehicle License Number
|veeter and Elliott Services LLC-O&AJason
Elliott P m i
7. Location where contents were disposed:
8LSD
10/3/2024
D ate
ignature of Receiving Facility Date
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