HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 258 BRIDGES LANE 5/12/2025 Commonwealth
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System Pumping Record
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 31OC[VIR15�351.
A, Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
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u�m�mat� Bridges
key to move your Address
ounm, do not
North Andover MA 01845
use the return
key. ~'^'''~`~' State Zip Code
2� System Owner:
~---^ Jim Healy
ame
a state -
ity/Town Zip Code
978-490-0983
B. Pumping Record
6/12/2O�5 1500
1. Date ofPumping 2. Quantity Pumped:
3. Type ofsystem: Cesspool(s) Z Septic Tank n Tight Tank El Grease Trap
n Other(describe):
4. Effluent Tee Filter present? X Yam [] No |f yes, was itcleaned? X Yes F1 No
5. Condition ofSystem:
Good md
O. System Pumped By:
Jason Elliott S71437 orV85257
a"e- Vehicle License Number
|veetmrand Elliott Services LLC-DBAJoaon
Elliott Pumping
7. Location where contents were disposed:
GLSD