HomeMy WebLinkAboutSeptic Pumping Slip - 24 CARLTON LANE 12/20/2016 Commonwealth of Massachusetts
16 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 24 Carlton Lane
key to move your Address
cursor-do not North Andover MA 01845-5603
use the return ---------- --- - ----
key. City/Town State Zip Code
VQ 2. System Owner:
Sarah Tower
Name
rehvn
Address(if different from location)
City/Town S tat e Zip Code
978-807-7202
Telephone Number
B. Pumping Record
6124/2015, 1000
1. Date of Pumping 9/21/2016 2. Quantity Pumped: -Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
,Goad, 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
.......... ...........
6/24/2015, 9/21/2016
idniUre-of"Hauler Date
Signature of Receiving Facility Date
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