HomeMy WebLinkAboutSeptic Pumping Slip - 48 WINDSOR LANE 12/20/2016 < . 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 48_W-n----d---sor Lane .......__.....-----
key
to move your Address
cursor-do not North Andover MA 01845-5636
use the return ............
key. City/Town State Zip Code
2. System Owner:
Daniel Weeder Jr.
Name
rerwn
...............
Address(if different from location)
Ityrrown State Zip Code
978-686-2626
Telephone Number
B. Pumping Record
10/14/2016 1500
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) E Septic Tank F-1 Tight Tank ❑ Grease Trap
F-1 Other(describe): .............
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
Pump more often, heavy solids. Good, system op e� properly --------
& System Pumped By:
Jason Elliott S71437
--1.1.1.111------------
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
10/14/2016 .............
MqrMi&of Hauler Date
Signature of Receiving Facility Date
t5form4.doc-03/06 System Pumping Record•Page I of 55