HomeMy WebLinkAboutSeptic Pumping Slip - 110 FARNUM STREET 5/8/2017 Commonwealth of Massachusetts
RECEIVED
-7 City/Town of North Andover
System Pumping Record MAV r r��
Form 4
I'DWN UF NUK�H ANWVER
FlEALTH DEPARTMENT
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 110 Farn um Street
key to move your Address
cursor-do not North AndoverMA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
Laurie Stevens
Name
—---—--------------- .......
Address(if different from location)
State Zip Code
978-807-0103
Telephone Number
B. Pumping Record
1. Date of Pumping 5/3/2017 2. Quantity Pumped: 1500
Date Gallons
3, Type of system: El Cesspool(s) 0 Septic Tank El Tight Tank n Grease Trap
F1 Other(describe): ...................
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes R'No
5. Condition of System:
Good, system operating properly
--1-1---- ............
6. System Pumped By:
Jason Elliott 571437
—----------------
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
QLSQ
5/3/2017
.............
)gnt of Hauler Date
Signature of Receiving Fa-c-ility- Date
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