HomeMy WebLinkAboutSeptic Pumping Slip - 79 JOHNNY CAKE STREET 12/20/2016 Commonwealth of Massachusetts
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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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 79 Jonney_Cake Street ------------ -------
............
key to move your Address
cursor-do not North Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
John Polli
Name
Address--(-i f-different from-1o"...cation-)"
City/Town State Zip Code
978-664-3404
Telephone Number
--------- ...
B. Pumping Record
1. Date of Pumping 11/30/2012, 2. Quantity Pumped: 1500
9/14/2016 Gallons
3. Type of system: F-1 Cesspool(s) 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 operating properly ................
6. System Pumped By:
Jason Elliott -- S71437
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Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott_Pu
7. Location where contents were disposed:
GLSI)
11/30/2012, 9/14/2016
'WeLtqE@,,of-Hauler Date
.............
Signature of Receiving Facility Date
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