HomeMy WebLinkAboutSeptic Pumping Slip - 461 SUMMER STREET 5/8/2017Important: When
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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
e) 2,01 I
'TOO OF N(A.<1,ri ANDOVER
kiEPA.Tri DEPARTMEI\fr
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:
461 Summer Street
Address
North Andover
City/Town
2. System Owner:
Russell Bilodeau
Name
Address (if different from location)
City/Town
MA
State
01845
Zip Code
State Zip Code
603-548-4734
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system: Cesspool(s)
Li Other (describe):
4. Effluent Tee Filter present?
5. Condition of System:
Good, system oprating properly
4/18/2017
Date
2. Quantity Pumped:
1500
Gallons
Septic Tank D Tight Tank D Grease Trap
cif No If yes, was it cleaned?
6. System Pumped By:
Jason Elliott
Name
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
SiTSature of Hauler
Signature of Receiving Facility
S71437
Vehicle License Number
4/18/2017
Date
Date
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