HomeMy WebLinkAboutSeptic Pumping Slip - 115 JOHNNY CAKE 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 CM R 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 115 Johnny Cake Street
key to move your Address
cursor-do not North Andover MA -0184.5
use the return Cityfrown State Zip I p-C..o,de
key.
2. System Owner:
tab
Laura Sincerbeaux.-----.-,-,-
Name
rertan
"Address(if different from
City/Town State Zip Code
910-988-9044
Telephone Number
B. Pumping Record
8/9/2016 1500
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 F-1 No If yes, was it cleaned? Yes D No
5. Condition of System:
Good, system o erating
properly
6. System Pumped By:
Jason Elliott S71437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
,,,Elliott Pumping
7. Location where contents were disposed:
GLSD,,
8/9/2016
. ..........
la4nalre-ef-Hauller Date
Signature�of Receiving ivi-n—g-F—acili—ty Date
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