HomeMy WebLinkAboutSeptic Pumping Slip - 125 GRAY STREET 12/20/2016 Commonwealth of Massachusetts
City/Town of North Andover
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 310 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 125 Gray Street —--------------
key to move your Address
cursor-do not North Andover MA 01845-6303
use the return ..............
key Cityfrown State Zip Code
VQ 2. System Owner:
Paul Robbat
Name
Address(if different from location)
City/Town State Zip Code
978-866-2961
_Telephone Number
B. Pumping Record
9/812014, 1015/2016 1000
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 0 Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
.Gq_qd,_system oper.ati.ng_pro rly
6. System Pumped By:
-Jason Elliott --,,-_------ 571437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott-Pumping,,
7. Location where contents were disposed:
GL$D
9/812014, 10/5/2016
artat, f Hauler Date
...........
Signature of Receiving Facility Date
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