HomeMy WebLinkAboutSeptic Pumping Slip - 383 SALEM 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 383 Salem Street
key to move your Address
cursor-do not North Andover MA 01845-3105
use the return —
key. City/Town State Zip Code
2. System Owner:
David Gray
Name
renan
Address(if different from location)
-6711y/To - ........ '---
City/Town stat-e. —ZipCode
978-884-6147
Telephone-N—umber
B. Pumping Record
9/16/13, 8/11/2016 1500
1. Date of Pumping Date ---- 2. Quantity Pumped: Gallons
1 Type of system: ❑ Cesspool(s) Z Septic Tank El Tight Tank E] Grease Trap
El Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
Good, system operating properly
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:
GLSD -- ----
9/16/13, 8/11/2016
Sig Lure 6 H Date
-----------
Signature of Receiving Facility Date
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