HomeMy WebLinkAboutSeptic Pumping Slip - 51 Wellington Way - 11/6/24 - Septic Pumping Slip - 51 WELLINGTON WAY 11/6/2024 Commonwealth �� Massachusetts
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System 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 aa 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 besubmitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CKAR 15.351
A. Facility Information
Important:When
filling out forms 1. Byahsm Location:
vn the computer,
use only the tab Wellington Way
key to move your *uonmo
cursor do not
North Andover MA 01845
use the nmum
wey. ~''''~'^ State Zip Code
2. System Owner:
^---~ Anne/Uiberti
Name
Ad—dres—s-(if—different from location)
Cityl-rown State Zip Code
978-482-6547
lephone Number
B. Pumping Record
1. Date of Pumping 11/6/2024 2� Quantity Pumped: 1500
DateGallons
3. Type ofsystem: Ej Cesspool(s) Septic Tank n Tight Tank R Grease Trap
R Other(describe):
4. Effluent Tee Filter present? Yea No If yes, was it cleaned? Yee No
5. Condition ofSystem:
Good, system operating
S. System Pumped By:
Jason Elliott 871437orV85267
Name Vehicle License Number
|vasterand Elliott Services LLC-UBAJaoon
Elliott Pumping
7. Location where contents were disposed:
GLSO
11/6/2024
S`@Mru're of Hauler
Signature of Receiving Facility Date
(5form4.doo^03/00 System Pumping Record^Page I of