HomeMy WebLinkAboutSeptic Pumping Slip - 62 FARNUM STREET 12/20/2016 (L
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 62 Farnum Street
key to move your Address
cursor-do not North Andover MA 01845
use the return
key. City/Town State Zip Code
VQ 2. System Owner:
Brian Hickey
Name
Address(if different from location)
CityTTown State Zip Code
.telephone Number
B. Pumping Record
4/13/2014, 4/6/2016 _1500
1. Date of Pumping Date _-____ - 2. Quantity Pumped: Gallons
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:
s�qernqperating properly --------
6. System Pumped By:
Jason Elliott
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
411312014, 4/6/2016
FkIn Date
Signature of Receiving Facility Date
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