HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 302 REA STREET 11/18/2025 Commonwealth Massachusetts
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System Pumping Record
Form 4
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 local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCyWR16.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 302 Rea Street
key mmove your Address
mmm-do not
North Andover [WA 81845-4821
use the re
turn
key� City/Town State Zip Code
2. System Owner:
~---� Elizabeth Gill
name
Address(if different from location)
City/Town State Zip Code
978-975-1622 978-718-3231
Number
B. Pumping Record
1. Date of Pumping Date11/18/2825 2. Quantity Pumped: 1500
Gallons
3. Type ofsystem: El Connpun|(a) E Septic Tank F-1 Tight Tank El Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? Yea No |f yes, was itcleaned? Yee No
5. Condition ofSystem:
Good, tom operating d
8. System Pumped By:
Jason Elliott S71437 orV85257
Name Vehicle License Number
|vesterand Elliott Services LLC-DBAJaoon
Elliott Pumping
7. Location where contents were disposed:
GLSO