HomeMy WebLinkAboutSeptic Pumping Slip - 166 DUNCAN DRIVE 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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 166 Duncan Drive
..........
key to move your Address
cursor-do not North Andover MA 01845-2231
use the return City[Town State Zip Code
key.
2. System Owner:
William Driscoll
Name
...........
Address(if different from location)
CityfTown State Zip Code
978-689-3307
Telephone Number
...... ......
B. Pumping Record
1. Date of Pumping 10/1512014, 2. Quantity Pumped: 1500
9/15/2016 -6-a'lio—n
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_operating roperly
6. System Pumped By:
Jason Elliott S71437
Name Vehicle. License Nu"mber-
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GL-SD
10/1512014, 9/15/2016
a-ure of Hauler Date
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Signature of Receiving Facility Date
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