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HomeMy WebLinkAboutSeptic Pumping Slip - 152 VEST WAY 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 152 Vest Way 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 Roche III Name Address(if different from location) State Zip Code 978-689-4833 Telephone Number B. Pumping Record 4/28/2016 1500 1. Date of Pumping Date——---- 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank F-1 Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No 5. Condition of System: Good, ..s stem operating properly.__...., ....... 6. System Pumped By: Jason Elliott 571437 Name License Number Ivester and Elliott Services LLC-DBA Jason Elliott Pumping 7. Location where contents were disposed: GLSD 4128/2016 %i 06 of Hauler Date .......... Signature of Receiving Facility Date t5form4.doc-03/06 System Pumping Record-Page 1 of 55