HomeMy WebLinkAboutSeptic Pumping Slip - 272 Bridges Ln - 10/11/24 - Septic Pumping Slip - 272 BRIDGES LANE 10/11/2024 Commonwealth
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Form 4
OEP has provided this form for use by local Boards ofHealth. Other forms may be used, but the
information must be substantially the same as that provided hare. 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 date in
accordance with 31DCK8R15.351,
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
27280U{�ESLANE
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cursor-do not
NORTH ANDOVER MA ' -
use the return
City/Town x�� ` _ `^ ' �/p uvv� —
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2. SystemOvvn�r ~ '
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Address(if different from-locatkiori)
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-City/-Town State Zip Code
Te�phoneNumbe
B. Pumping Record
1. Dabs of Pumping Date
2� Quantity Pumped: 1500
Gu|xms
3. Component: El Cesspool(s) E Septic Tank Ej Tight Tank Fl Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? [l Yes Fl No |f yes, was itcleaned? F� Yes Fl No
5. Observed condition of component pumped:
GOOD CONDITION
0. System Pumped By:
JAY CURRIER H79406
Name Vehicle License Number
J'G SEPTIC & DRAIN
Company
7. Location where contents were disposed:
10/11/24
S' ature of Hauler Date
s|gnamnaorReceiving Facility(or attach facility naoe|p0 Date
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