HomeMy WebLinkAboutSeptic Pumping Slip - 40 EQUESTRIAN DRIVE 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, 40 Equestrian Drive —-----
use only the tab ---- --
key to move your Address
cursor-do not North Andover MA 01845
use the return City/Town State Zip—_......m...._.Code
key.
2. System Owner:
Kristen Sgrosso . .....
Name
renrn
Address(if different from location)
City/Town State Zip Code
978-793-3182
Telephone Number
B. Pumping Record
4/22/2016 1500
1. Date of Pumping "baie" — __ 2. Quantity Pumped: Gallons
3, Type of system: ❑ Cesspool(s) Z 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 operatin _pro erl
6. System Pumped By:
Jason Elliott 571437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott.-Pump'
7. Location where contents were disposed:
QLSD
4/22/2016
Date
Signature of Receiving Facility Date
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