HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 49 WINDSOR LANE 1/9/2025 Own
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System Pumping Record
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Form 4
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DEP has provided this for use by local Boards of Health. Other may bdu?9,/
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 310CIVIR15.351.
A, Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 48 Windsor Lane
key m move your xuumo
cursor-«»not North Andover MA 01845
use the mmm
City/Town StateZipuouv
_'.
2. System Owner:
�---� KennothVeduUo
State Zip Code
817-438-6600
B. Pumping Record
01/9V2025 1600
1. Date of Pumping Date 2. Quantity Pumped: Galloris
3. Type of system: D Cesspool(s) Z Septic Tank n Tight Tank n Grease Trap
Fl
�~ Other(describe):
4. Effluent Tee Filter present? X Yes El No |f yes, was i(cleaned? X Yea No
5. Condition of System:
Good, ba operatingproperly
G. System Pumped By:
Jason Elliott S71437urV85257
|veaierand Elliott Services LLC-DBAJaeon
Elliott Pumping
7. Location where contents were disposed:
GLSD