HomeMy WebLinkAboutSeptic Pumping Slip - 1353 Salem St - 10/4/24 - Septic Pumping Slip - 1353 SALEM STREET 10/4/2024 Commonwealth �� Massachusetts
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Form
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must bm substantially the same as that provided hero. 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 |mco| Board of Health or 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 1353sa|emStreet
key to move your Adumoo
cursor-do not
North Andover MA 01845
use the nuum
mav� ~'"''~`~' State Zip Code
2. System Owner:
�---^ James Keefe
Address(if different from location)
978-821-2720
fe le-phone Number"
B. Pumping Record
10M/2024 15OO
1. Date of Pumping 2. C>uant�yPumped:
3. Type ofsystem: Fl Cesspool(s) Septic Tank [l Tight Tank [:1 Grease Trap
LJ Other(describe):
4. Effluent Tee Filter present? Yes No |f yes, was iicleaned? Yes No
5. Condition of System:
Good system tiproperly
G. System Pumped By:
Jason Elliott S71437 or V85257
me Vehicle License Number
|waober and Elliott Services LLC-DBAJason
Elliott P m p i
7. Location where contents were disposed:
GLSD