HomeMy WebLinkAboutSeptic Pumping Slip - 70 LIBERTY STREET 5/8/2017 Commonwealth of Massachusetts RECEIVED
City/Town of North Andover MAY 08 010
System Pumping Record TOWN UF NUK,I H AMMER
Form 4 HEALTH DEPARTMENT
e.
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.
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A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 70 Liberty Street --------------
key to move your Address
cursor-do not North AndoverMA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
Rodrigo Laureano
Name
rnnrn
Address(if different from location)
City/Town State Zip Code
203-778-9309
Telephone Number
B. Pumping Record
4/19/20171500
1. Date of Pumping 2. Quantity Pumped: ....... —
Date Gallons
3. Type of system: El Cesspool(s) 0 Septic Tank El Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes No
5. Condition of System:
Good, system operatin _pr p
o
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6. System Pumped By:
Jason Elliott 571437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pump,lRg
7. Location where contents were disposed:
GLSD
4/19/2017
natGie of Hauler Date
Signature of Receiving Facility Date
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