HomeMy WebLinkAboutSeptic Pumping Slip - 255 OLD CART WAY 12/20/2016 Commonwealth 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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 255 Old Cart.Way .............
key to move your Address
cursor-do not North Andover MA 01845
use the return
key. CityfTown State Zip Code
VQ 2. System Owner:
Jennifer Thorn
Name
----------
Address(if different from location)
CityrTown State Zip Code
617-828-1120
Telephone Number
B. Pumping Record
10/13/2016 2. Quantity Pumped: 1500
1. Date of Pumping
Gallons"—
Date
1 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:
Good, system operating properly_.. --
6. System Pumped By:
Jason Elliott 571437
Name Vehicle License Number
Nester and Elliott Services LLC-DBA Jason
-.Elliott Purnpiqq-
7. Location where contents were disposed:
GLISD
10/13/2016
Date
Signature of Receiving Facility Date
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