HomeMy WebLinkAboutSeptic Pumping Slip - 926 FOREST STREET 5/8/2017 (2) 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 926 Forest Street
key to move your Address
cursor-do not North Andover MA 01845-3324
use the return
key. City/Town State Zip Code
VQ 2. System Owner:
John'.Lon.g_y'eil .. ........ ..........
Name
rens
-Address. "(if different from location)
City/Town State Zip Code
Telephone Number
................----------- -------------- -------------------------- --------- ---------------- -------------------------------------------- -------------------- ------ -------------..-..-----
B,
----------------------------
B. Pumping Record
1. Date of Pumping 5/2/2017 2. Quantity Pumped: 1000
Date Gallons
3. Type of system: El Cesspool(s) E Septic Tank El Tight Tank El Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes No
5. Condition of System:
Good, system operating
& System Pumped By:
-Jason Elliott 571437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumpinq
7. Location where contents were disposed:
GLSD
5/2/2017
qEHauIe_r Date
............ —--------------- ..................—-------------___-_-_- -------—----____-
Signature of Receiving Facility Date
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