HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 21 DEER MEADOW ROAD 11/18/2025 Commonwealth Massachusetts
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System Pumping Record
Form 4
Y",
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must bu 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 dote in
accordance with 31OCK4R15.851.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,use only the tab 21 Deer Meadow Road
key w move your Address
uumn, do not
NorthAndovor MA 81845'1440
use the mmm
key. City/Town State Zip Code
2. System Owner:
^---~ Jeffrey Faucon
Name
g78'533-9247
6�6.
�� Pumping
Record
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1. Date of Pumping oa\*11/18/2025 2. Quantity Pumped: 1500
Gallons
3. Type ofsystem: F-1 Cesspool(s) E Septic Tank El Tight Tank El Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? Yea No |f yes, was itcleaned? Yes No
5. Condition ofSystem:
Good system dproperly
0. System Pumped By:
JasonE||ioU S71437 or V85257
Name Vehicle License Number
|veater and Elliott Services LLC-DBAJason
ElliottPumping
7. Location where contents were disposed:
GLSD
11/18/2025
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