HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 448 BOXFORD STREET 12/30/2024 Commonwealth of Massachusetts
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Pumping
Record
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System u- ��
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 |onm| Board of Health or other approvinA authority within 14 days from the pumping date in
accordance with 310CK4R15.351.
A. Facility Information
Important:When
filling out ronna 1. System Location:
on the computer,
use only the tab 448 Boxford ��nset
key to move your »mdmas
oumu,-do not
North Andover MA 01845
use the return
kev. City/Town State Zip Code
2. System Owner:
�--�' Ryan Hale
Wme
^--~�--^ Address- (ifdiOe rent from- location)
City/Town State Zip Code
315-345-8877631-258-6808
B. Pump~ng Record
12/3U�O�� 1�OO
1. Date of Pumping 2� Quantity Pumped�
Gallons
3. Type ofsystem: Cesspool(s) Z Septic Tank Tight Tank El Grease Trap
E] Other(describe): ----
4. Effluent Tee Filter present? X Yea [l No |f yes, was itcleaned? X Yes E] No
5. Condition ofSystem:
Tank and chamber Good, system operating
6. System Pumped By:
Jason Elliott S71437nrV85257
|vee(erond Elliott Sen/ioae LLC-OBAJoemn
Ell iottPum i
7� Location where contents were disposed:
8LBD