HomeMy WebLinkAboutSeptic Pumping Slip - 110 DUNCAN DRIVE 12/20/2016 11
D-\ Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
DPP 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 CM R 15.351.
..........
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 110 Duncan Drive
key to move your Address
cursor-do not North Andover MA 01845-2231
use the return ...........
key. City/Town State Zip Code
2. System Owner:
Linda Cahill
Name
-Address(if different from location)
----------
City/Town State Zip Code
978-208-8638
Telephone Number
B. Pumping Record
5/28/2014, 7/6/2016 1500
1. Date of Pumping Date- 2. Quantity Pumped: Gall.1 on 11,s
3. Type of system: ❑ Cesspool(s) 0 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:
Good, system operating proper
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
5128/2014, 7/6/2016
.
...... .........
Signature of Hauler Date
Signature of Receiving Facility Date
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