HomeMy WebLinkAboutSeptic Pumping Slip - 8 EVERGREEN DRIVE 5/8/2017Important: When
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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
P.' 7"
1014 °I; 141Q‘ ER
DEpp8TMENT
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
1,
System Location:
8 Evergreen Drive
Address
North Andover MA
State
City/Town
2. System Owner:
Michael Kishinevsky
Name
Address (if different from location)
01845
Zip Code
City/Town
State Zip Code
978-683-2107 908-557-3842
Telephone Number
B. Pumping Record
1. Date of Pumping
4/14/2017
Date
3. Type of system: El Cesspool(s)
El Other (describe):
4. Effluent Tee Filter present? Yes
5. Condition of System:
Good, system operating properly
6. System Pumped By:
Jason Elliott
1.1
2. Quantity Pumped:
1500
Gallons
Septic Tank Ej Tight Tank 11 Grease Trap
No If yes, was it cleaned? Yes No
Name
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
Signe ure of Hauler
Signature of Receiving Facility
S71437
Vehicle License Number
4/14/2017
Date
Date
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