HomeMy WebLinkAboutSeptic Pumping Slip - 134 Olympic Ln - 11/9/24 - Septic Pumping Slip - 134 OLYMPIC LANE 11/9/2024 �� Commonwealth �� Massachusetts
��` `����[������/u / �/
/�'��T mfKJ North Andover
���� ��/� �� � over
vw` �' / `�/ /� / v / r� `�
Pumping
Record
k.w
������00 n �K��U�� o�����"�
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 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 310CK8R15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 134 Olympic Lane
key m move your xuu,enm
cursor do not
North Andover yW/\ 01845-3314
use the return
key. c|tynvwn State Zip Code
2. System Owner:
~---� Theresa Hardy
Name
Address(if different from location)
uonfow—n -Stat Zip Code
978-258-9693978-239-6059
Telephone Number
B. Pump'ng Record
11/9/2024 1250
1. Date ufPumping Date 2. Quantity Pumped. Gallons
3. Type ofsystem: El Cesspool(s) Septic Tank [l Tight Tank El Grease Trap
[l Other(describe):
4. Effluent Tee Filter present? Yea Z No |f yes, was itcleaned? Yea No
5. Condition ofSystem:
Good system operating d
G. System Pumped By:
Jason Elliott 871437orV85257
Name Vehicle License Number
|veeter and Elliott Services LLC-OBAJason
Elliott Pumping
7. Location where contents were disposed:
GLGD
11/9/2024
S`igMXTre of Hauler Date
si—gri—ature of Receiving Facility Date
\5fonm4.doo^03/0e System Pumping Record~Page ao,e