HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 79 VEST WAY 8/20/2025 �.�
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Pumping
Record "
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Form 4
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DEP has provided this form for use by local Boards ofHeokh. Other forms may be used��q�Wey]t
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 31OCMR15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 78 Vest Way
key to move your ^mumsr
cursor-do not
North Andover MA 01845
� m use the tu
key. ~''''~``'' ~~^~ Zip Code
2. System Owner:
~---~ Karen Manning
978-815-5207
Telephone Number
B. Pumping Record
8/20/2O25 15OO
i. Date of Pumping 2 Quantity
oom ' � Gallons
3. Type of system: El Cesspool(s) Septic Tank n Tight Tank n Grease Trap
LJ Other(describe):
4. Effluent Tee Filter present? Yee No U yes, was itcleaned? Yes E No
5. Condition of System:
Good system b d
Q. System Pumped By:
Jason Elliott S71437 or V85257
Vehicle License Number
|vemk+r and Elliott Services LLC-DQAJason
B|ioftPum ping
7. Location where contents were disposed:
BLSO
8/20/2025
ignature of Receiving Facility Date
t5mnn4.onn^03/08 System Pumping Record^Page 2me