HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 LACY STREET 8/1/2025 Commonwealth �� Massachusetts
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System Pumping
Record
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Form
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DEP has provided this funn 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
|ooe| Board of Health to determine the form they use, The System Pumping Record must be submitted to
the local Board ofHealth or other approving authority within 14 days from the pumping date in
accordance with 31OCK4Ri5.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 45Lo Street
key to move your mmmao
uvm^r do not
North Andover [W/\ 01845
use the n�vm
xev� City/Town State ^'p~~~~
2. System Owner:
~---� K8inhom| Hale
Na-me
ress(if different from location)
cityaown State Zip Code
847-924-6379
B. Pumping Record
1. Date of Pumping 8/1/2025 2� Quantity Pumped: 1500
b-ate3. Type ofsystem: n Cesspool(s) Septic Tank n Tight Tank Grease Trap
i] Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yea [I No
S. Condition of System:
Good system tiproperly,
8. System Pumped By:
Jason Elliott S71437 orV��2�y
ame Vehicle License Number
|veabarand Elliott Services LLC-DBAJoaon
Elliott Pum i
7. Location where contents were disposed:
GLSD