HomeMy WebLinkAboutSeptic Pumping Slip - 953 Johnson St - 11/13/2024 - Septic Pumping Slip - 953 JOHNSON STREET 11/13/2024 Commonwealth �� Massachusetts
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Pumping
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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 as that provided here. Before using this fonn, check with your
local Board of Health(u 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 31OCKxR15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 953Johnoon Street
key to move your Address
cursor do not
North Andover MA 01845
use the ngum
key. ~'''~^^ ~^�^~
2. System Owner:
~---� LesGchnake
Name
State Zip Code
978-387-8027
B. Pumping Record
11/13/2024 1500
1� Date ofPumping 2� Quantity Pumped:
Gallons
3. Type ofsystem: Fl Cesspool(s) Z Septic Tank R Tight Tank F] Grease Trap
LJ Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yea Z No
5. Condition ofSystem:
Tank cover cracked in half G ud s tem operatingproperly
G. System Pumped By:
Jason Elliott S71437 orVO5257
Name Vehicle License Number
|vooherand Elliott Services LLC-DBAJoson
Elliott Pumping
7. Location where contents were disposed:
GLSD
11/13/2024
-%�Ire of Hauler Date
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