HomeMy WebLinkAboutSeptic Pumping Slip - 35 PENNI LANE 12/20/2016 Commonwealth of Massachusetts
City/Town of North Andover
...........
System Pumping Record
ti 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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 35 Penni Lane
key to move your Address
cursor-do not North Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
rab
Norma Lochmann
Name
reran
Address(if different from location)
-dityfrown -State -Z-ipCod-e"-
978-658-2164
Telephone Number
B. Pumping Record
1. Date of Pumping 111712013, 2. Quantity Pumped: 1000
9122/2016 Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank n Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
q
.God,_system operating properly
-. ...... _ _��ra
6. System Pumped By:
Jason Elliott S71437
Name -- --V"-,e,hi,c-,Ie-,"L-icense-Number..........
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
...........
11/7/2013, 9/22/2016
Sitg�rrefiare of Hauler D ate
---------Signature of Receiving Facility Date
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