HomeMy WebLinkAboutSeptic Pumping Slip - 67 VEST WAY 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 67 Vest Way.
key to move your Address
cursor-do not North Andover MA 01845
use the return
key State Zip Code
VQ 2. System Owner:
Glenn Schmidt
Name
ream
-------------
Address(if different from location)
City/Tawn -State,"""-"- - Zip-Code ------ ------
978-685-5736
Telephone Number
B. Pumping Record
1. Date of Pumping 8/20/2013, 2. Quantity Pumped: 1500
9/27/2016 Gallons
3. Type of system: ❑ Cesspool(s) E Septic Tank F-1 Tight Tank ❑ Grease Trap
❑ Other(describe): --------
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes El 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-PUMPD9-----r'--1--11-1--'---- -
7. Location where contents were disposed:
Z8/20/2013, 9/27/2016
Si4&na _ Date
Signature of Receiving Facility Date
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