HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 305 BOSTON STREET 5/29/2025 Commonwealth nfMassachusetts
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System Pumping
Record
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Form 4
DEP has provided this form for use by|u*a| Boards of Health. Other forms may be used, but the
information must be substantially the oomm 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[WR15.351
A, Facility Information
Important:When
filling out forms 1. System Location:
o^the computer,
use only the tab 305Bp�un �tnaet
key uz move your Address
wrsor-u«n«t North Andover MA 01845
use memmm
key. City/Town State Zip Code
2. System Owner:
~---~ NiehiteOzo
-Address(if different from location)
878-784-8751
Tele"Phone Number
B. Pumping Record
5/2Q/�O25 1500
1. Date ofPumping 2. Quantity Pumped: Gallons
3. Type ofsystem: F1 Cesspool(s) Septic Tank n Tight Tank El Grease Trap
L| Other(describe):
4. Effluent Tee Filter present? Yes Z No If yes,was it cleaned? Yea No
5. Condition of System:
Good, system ndi |
G. System Pumped By:
Jason Elliott 371437orV85257
ame Vehicle License Number
|voeterund Elliott Services LLC-mBAJamon
Elliott Pumping
7. Location where contents were disposed:
GLSD
5129/2025
-es of Hauler
ignature of Receiving Facility Date
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