HomeMy WebLinkAboutSeptic Pumping Slip - 199 STONECLEAVE ROAD 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 199 Stonecleave Road
key to move your Address
cursor-do not North Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
Corliss
Name
izrwn
Address(if different from location)
City[Town State Zip Code
978-317-2503 617-599-2203
Telephone Number
B. Pumping Record
1, Date of Pumping 4/7/2014, 2. Quantity Pumped: 1500
1012512016 -Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ 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 operating properly, ......
6. System Pumped By:
Jason Elliott 571437
lName ...... Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
4/7/2014, 10/25/2016
Si nature of Hauler Date
Signature of Receiving Facility Date
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