HomeMy WebLinkAboutSeptic Pumping Slip - 800 Johnson St - 10/7/24 - Septic Pumping Slip - 800 JOHNSON STREET 10/7/2024 Commonwealth Massachusetts
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Record
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Firm 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 |oos| 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:
mn the computer,
use only the tab 8OO Johnson Street
keym move your ^dgmas
cursor do not
North Andover ��A 01845-3O88
use the n$um
xny� City/Town State Zip Code
2. System Owner:
~---~ Stephen Elbe
Name
803-702-0238
B. Pumping Record
18/�/2O24 1GO0
1 Date 2 Quantity� Date � � Gallons
3. Type ufsystem: Fl Cesspool(s) Septic Tank n Tight Tank El Grease Trap
E] Other(describe):
4. Effluent Tee Filter present? Yes Z No |f yes, was itcleaned? Yoe Z No
5. Condition ofSystem:
Good, dproperly
6. System Pumped By:
Jason Elliott S71437 or V85257
Name Vehicle License Number
|w*oter and Elliott Services LLC-DBAJason
Elliot t Pu mp in
7. Location where contents were disposed:
GL8U
10/7/2024
_f,���_ur'-o-f Hauler- Date
Signature of Receiving Facility Date
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