HomeMy WebLinkAboutSeptic Pumping Slip - 72 Windsor Ln - 11/13/2024 - Septic Pumping Slip - 72 WINDSOR LANE 11/13/2024 Commonwealth mfR�Massachusetts
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Form 4
DEP 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 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 date in
accordance with 310CN1R 15.351.
A, Facility Information
Important:When
filling out mmm 1. System Location:
on the computer,
use only the tab 72 Windsor Lane
x*vm move your Address
cursor do not
North Andover MA 01845-5636
use the return
key. City/Town State Zip Code
2. System Owner:
^---~ Adam Davies
me
n State Zip Code
978-404-9079
Telephone Number
B, Pump'ng Record
11/13/2024 1500
1� Date cfPumping Date 2. Quantity Pumped. Gallons
3. Type ufsystem: Cesspool(s) Septic Tank n Tight Tank [l Grease Trap
[] Other (describe):
4. Effluent Tee Filter present? Yen No |f yes, was itcleaned? Yoe No
5. Condition ofSystem:
Good system operating properly
6. System Pumped By:
Jason Elliott S71437 or V85257
|veder and Elliott Services LLC-DBAJason
B|iottPum ping
7. Location where contents were disposed:
GLSD
11/13/2024
SI ure of Hauler Date
gnature of Receiving Facility Date
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