HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 164 BRIDGES LANE 11/18/2025 Commonwealth Massachusetts
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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 |noa| Board of Health Or other approving authority within 14 days from the pumping date in
accordance with 310CyVIR15.351.
A~ Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 164 Bridges Lane
keymmove your Address
ovmvr do not
North Andover MA 01845-2224
use the nn"m
--
key. City/Town State Zip Code
2. System Owner:
~---~ Pau| DeLuC8
mema
Address(if different from location)
n State Zip Code
781-367-0044
Telephone Number
B. Pumping~ng Record
=
11/18/2O�5 1�OO
1 Date 2 Quantity� Dom � � oa||uno
3. Type of system: Cesspool(s) Septic Tank Fl Tight Tank F-1 Grease Trap
Fl Other(describe):
4. Effluent Tee Filter present? Yen No K yes, was kcleaned? Yes No
5. Condition of System:
Good, system hproperly
8. System Pumped By:
JaoonB|iutt G71437orV85257
Name Vehicle License Number
|veater and Elliott Services LLC-DBAJason
Elliott Pumping
7. Location where contents were disposed:
GLSO
11/18/2025
S,%__ ur,�r uller' —--------- Date
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