HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 187 STONECLEAVE ROAD 1/11/2025 rOW/7 Of
Commonwealth Massachusetts �~'
�����l��(�D\8/����/" . `�/ /v/����������/ /U��~^^"� �Ior-'��/�o&er
��'fny� � hJ North Andover.�|� ��D � � � [3V��[ ��
y/ / / /�, / u / r� �� ' ��� �"� �3r�
��yste�� ��u����Dng Record
= ~ ~��
Form 4
OEP has provided this form for use by local Boards of Health. Other formshe
information must be subetantiaUythe same oe that provided here. Before using this
form, Aok with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the i000| Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310CIWR15.351.
A, Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use un�the m lD7StonedoeveDrive
key m move your Address
cursor do not NodhAnduver MAU1845
use the nxm u
x*;. City/TownStam Zip Code
2. System Owner:
�---" Erin Carcie
617-201-8024
Telephone Number
B. Pumping Record
1� Date of Pumping 7/11/2025 2� Quantity Pumped: 1500
Gallons
3. Type ofsystem: F1 Cesspool(s) Z Septic Tank [l Tight Tank n Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? Yes Z No |f yes,was itcleaned? Yes Z No
5. Condition of System:
Good, t r dnproperly
6. System Pumped By:
Jason Elliott S71437urV85257
|veoterund Elliott Sen/imam LLC-OBAJauon
Elliott P m i
7. Location where contents were disposed:
GLSO
%S, ,,—e,f--ka--u-1er --Date—--—---------
so
ignature of Receiving Facility Date
mmnn4.000'03/0e System pumping eooum^pugo 2 of