HomeMy WebLinkAboutSeptic Pumping Slip - 36 WINDSOR LANE 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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 36 Windsor Lane
key to move your Address
cursor-do not North Andover MA 01845
use the return
key. Cityfrown State Zip Code
2. System Owner:
rib
Thomas Royce ..........
Name
retwn
Address(if different from location)
State Zip Code
781-413-7092
Telephone Number_______
B. Pumping Record
10/14/2016 1500
1. Date of Pumping Date 2. Quantity Pumped: Gallons
1 Type of system: ❑ Cesspool(s) Z Septic Tank [:1 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,,-s.ystem operating'.p
rqperly ....
6. System Pumped By:
Jason Elliott 571437
Na—me Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
10/14/2016
Si ll t- Date
Signature of Receiving Facility Date
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