HomeMy WebLinkAboutSeptic Pumping Slip - 146 FARNUM 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 115�351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 146 Farnum Street
key to move your Address
cursor-do not North Andover 01845
use the return Cityfrown State Zip Code
key.
2. System Owner:
Kevin Sheehan
Name
............ -------------
Address(if different from location)
-6-ity/Town St—ate ' -Z""lp-C o--d-e--"
-;rei - --- -.............
lephone Number
B. Pumping Record
716/2016 1500
1. Date of Pumping Date - .......... 2. Quantity Pumped: Gallons
3. Type of system: El Cesspool(s) Septic Tank F Tight Tank F-1 Grease Trap
Other(describe): --------------
4. Effluent Tee Filter present? Yes F] No If yes, was it cleaned? Yes No
5. Condition of System:
Good, system operating properly
..........
6. System Pumped By:
Jason Elliott S71437
14—ame " -- -- '"............. -V-ehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD ,
7/6/2016
i"atufe of Hauler Date
...........
I--S nature of R'e-c-eiv"ing Facility Date
ig
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