HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 24 CARLTON LANE 11/24/2025 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 hen*. 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 310CIWR15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 24 Carlton Lena
key tu move your xuumss
cursor do not
North Andover MA 01845-5883
use the return
---
key. City/Town State Zip Code
2. System Owner
~---� Sarah Tower
Name
Address(if different from location)
wn State Zip Code
978-807-7202
Telephone Number
B. Pumping
Record
�°. � �00�U��� "~�����=
11/�4/�0�5 15OU
1 Date of 2 Quantity Pumped:� Date � � 6aUnna
3. Type of system: Cesspool(s) Z Septic Tank [l Tight Tank F� Grease Trap
n Other(describe):
4. Effluent Tee Filter present? Yee Z No |f yes, was itcleaned? Yes Z No
5. Condition of System:
Good system U |
8. System Pumped By:
Jason Elliott S71437 orV85257
Name Vehicle License Number
|veater and Elliott Services LLC-DBAJason
Elliott Pumping
7. Location where contents were disposed:
GLSD
%Siure of Hauler Date
Signummof Receiving FeoiUty Du*a
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