HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 864 WINTER STREET 7/24/2025 Commonwealth Massachusetts`�OMlUO{JDVV��/u / w m/����u. vU���^� rowo Of/V0�/ �
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System Pumping Record ~"n 112025
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Form 4
OEP-has provided this form for use by local Boards of Health. Other
information must baoub�aodaU Before thi�f��� th your
local Board of Health to determine the form they use. The System Pumping Record must beaUMiUadkz
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCK4R15.351.
A~ Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tau 8O4V0nb�S�eo�
meymmove your Address
cursor-do not
North Andover MA 01845
use�n�mm
key. City/Town ~a~ Zip Code
2. System Owner:
��� /ran
617-913-6328
Telephone Number
B. Pumping Record
7/24/2025 i5OO
1. Dote of Pumping 1 Oumntity Pumped.
ons
3. Type cfsystem: F-1 Cesspool(s) Septic Tank Tight Tank Grease Trap
LJ Other(describe):
4. Effluent Tee Filter present? Yen No |f yes, was itcleaned? Yes No
5. Condition ofSystem:
Good system dproperly
0. System Pumped By:
Jason Elliott S71437orV85257
ame Vehicle License Number
|veeAar and Elliott Services LLC-DBAJason
Elliott Pumping
7. Location where contents were disposed:
GLGD
7/24/2025
%S' 're of Hauler 15-ate- __ - ___
Signature Date