HomeMy WebLinkAboutSeptic Pumping Slip - 45 LACY 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 CUIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 45 Lacy Street ................
key to move your Address
cursor-do not North Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
Michael Hale
Name
-A-d�-" """" "'""-
ress(if-d-"i-ff-e-r-e--n-t–fromi—ocatio—n) ........ ............
............
City/Town State Zip Code
847-924-5379
Telephone Number
B. Pumping Record
513/2011, 5/17/2016 1500
1. Date of Pumping 2. Quantity Pumped: ---
Date Gallons
3. Type of system: ❑ Cesspool(s) E Septic Tank El Tight Tank ❑ Grease Trap
❑ Other(describe): ------
4. Effluent Tee Filter present? Yes F-1 No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
Good, system opgraj
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
5/3/2011, 5/17/2016
Signature-igngt(fre of Hauler Date
-Signature oi-ke-"c"-eI-v-in-"g--'F--ac-il-ity Date
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