HomeMy WebLinkAboutSeptic Pumping Slip - 42 PENNI LANE 6/7/2017 Commonwealth of Massachusetts RECEIVED
City/Town of North Andover
System Pumping Record I A
J
Form 4
DEPNUNILNT
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 42 Penni Lane
key to move your Address
cursor-do not North Andover MA 01845-6209
use the return --1-1--................11........... —------
key. City/Town State Zip Code
VQ 2. System Owner:
Matthew Savory
terra
Address(if different from location)
City[Town State Zip Code
978-609-8253
Telephone
iphone Number
B. Pumping Record
6/7/2017 1500
1. Date of Pumping -Date
D-ate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank R Tight Tank El Grease Trap
n Other(describe): ----------
4. Effluent Tee Filter present? Yesj No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
Good,
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:
G LSD
6/7/2017
ignatl of Hauler Date
Signature of Receiving f acility Date
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