HomeMy WebLinkAboutSeptic Pumping Slip - 302 REA 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 302 Rea Street
key to move your Address
cursor-do not North Andover MA 01845-4821
use the return
key. CityfTown State Zip Code
2. System Owner:
Walter Gill
-Na me
ratan
Address(if di#ere'ii t ir-orn-location)
CityTrown State Zip Code
978-975-1622
Telephone Number
B. Pumping Record
7/23/2015, 9/112016 1000
1. Date of Pumping
Date __ 2. Quantity Pumped: Gallons-
3. Type of system: ❑ Cesspool(s) H Septic Tank F1 Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
_Good, system qe
,Ipraltfn properly
- - _ _��rop
6. System Pumped By:
Jason Elliott 571437
Name Vehicle License Number _
Ivester and Elliott Services LLC-DBA Jason
7. Location where contents were disposed:
GLSD
7/23/2015, 9/1/2016
§fg-nature of Hauler Date
-.---- ------
Signature of Receiving Facility Date
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