HomeMy WebLinkAboutSeptic Pumping Slip - 24 DEER MEADOW ROAD 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 24 Dear Meadow
key to move your Address
cursor-do not North Andover MA 01845
use the return
key. City/Town State Zip Code
VQ 2. System Owner:
Deer Meadow LLC
Name
aasn
Address(if different from location)
-City/Town State —Code
617-970-5637
Telephone Number
B. Pumping Record
02/18/2016 1500
1. Date of Pumping Date 2. Quantity Pumped: Gallons
-11 1 ons
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:
'Pogo, system ,�era_qp operating properly
6. System Pumped By:
Jason Elliott 571437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pum
7, Location where contents were disposed:
LSD
02/18/2016
Date
Signature of Receiving--_F an i 1it y —----- Date
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