HomeMy WebLinkAboutSeptic Pumping Slip - 174 GRAY STREET 12/20/2016 Commonwealth of Massachusetts
City/Town of North Andover
............
............ System Pumping Record
Form 4
Vb
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 174 Gray Street
key to move your Address
cursor-do not North Andover MA 01845-6302
use the return
key. City/Town State Zip Code -------
2. System Owner:
tab
Leonard Robinson Jr.
Name
atarn
Address(if different from location)
----------
CityfTown State -Zip-Code
508-208-5870
------------
Telephone Number
B. Pumping Record
10/25/2016 1500
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ 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:
_qqqqq,_ stem operating_p ___-----
Tqperly
6. System Pumped By:
Jason Elliott 571437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7, Location where contents were disposed:
G11LSD
10/25/2016
Signature of Hauler Date
-Signature--o--f---Receiving—Facility"- -Date ------
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