HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 383 SALEM STREET 1/6/2025 Commonwealth Massachusetts��`�D1Dq��D\A/�|��/�. . ^�/ .".����������. .U��~^`"� row'' v' �W�mW�
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Pumping
Record F��
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0EP has provided this form for use by local Boards of Health. Other forms �d but the
information must ba substantially the same as that provided here. Before using thi R##;e
th your
local Board ofHoakhtodetermine the form they use. The System Pumping Record must beSgittodto
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31UCyWR15.351.
A, Facility Information
Important:When
filling out forms 1. System Location:
um the computer,
use only the tab 3O3Sa|amStnaat
key to move your xo*msn
cursor-do not
North Andover MA O1O4�-3185
use the e$um
---
key. City/Town State Zip Code
2. System Owner:
"---� David Gray
Name
ss(if different from location)
978-884-6147
B~ Pumping Record
U1/8/2U25 15O8
1. Date of Pumping bate- 2� Quantity Pumpad�
Gallons
3. Type ofsystem: [| Cesspool(s) E Septic Tank [l Tight Tank Fl Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? Yea Z No |f yes, was Kcleaned? Yes Z No
6. Condition of System:
Good, system dproperly
8. System Pumped By:
Jason Elliott S71437orV85257
Name Vehicle License Number
|wsoher and Elliott Services LLC-OBAJason
Elliott Pumping
7. Location where contents were disposed:
GLSO
01/6/2025
%S, .r of Hauler-
.-sig-n-ature-of Receiving-Facility- Date
mmnn4.uoc^03m6 System Pumping Record^Page Im*