HomeMy WebLinkAboutSeptic Pumping Slip - 229 Gray St - 11/1/2024 - Septic Pumping Slip - 229 GRAY STREET 11/1/2024 Commonwealth r� Massachusetts /-
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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 ma 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 31OCK8R15.3S1.
A. Facility Information
Important:When
filling out forms 1. System Location:
nn the computer,
use only the tab 229 Gray Street
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NorthAndovor MA 01845
use memmm
key. ..,..~~. State Zip Code
2. System Owner:
~---~ JaeonDiphmo
Name
nn��vwn mate Zip Code
978-802-3027
Telephone Number
B. Pumping Record
1. Date ofPumping 11/1/2024 2� {3uonhtyPumped� 1500
DateGaulons
3. Type of system: El Cesspool(s) 2 Septic Tank M Tight Tank M Grease Trap
[l Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes No
5. Condition ofSystem:
Good, system operating
6. System Pumped By:
Jason Elliott S71437 or V85257
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|veoherand Elliott Services LLC-DBAJoaon
Elliott Pumping
7. Location where contents were disposed:
GLSD
11/1/2024
Si�'�re of Hauler Date
_signaturioMecemng Facility Date
mfom*dou^0308 System Pumping Record^Page 1ov8