HomeMy WebLinkAboutSeptic Pumping Slip - 414 FOSTER STREET 6/29/2017 Commonwealth of Massachusetts RECEIVED
City/Town of North Andover JUN` � 9
System Pumping Record TOWN OF NUR�+i ANDOVER
Form 4 F�EAJ�Ui 01VARTMS,�'T
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 414 Foster Street
key to move your Address
cursor-do not North AndoverMA 01845
use the return City/Town —----------- —-------------
key. State --------------- Zip Code
Z System Owner:
.Jason Harding .............
Name
Address(if different from location)
CityfTawn State Zip Code
781-640-3927
Telephone Number
B. Pumping Record
6/20/2017 1000
1. Date of Pumping -Date_______.._________-- 2. Quantity Pumped: Gallons
1 Type of system: ❑ Cesspool(s) 0 Septic Tank F1 Tight Tank n Grease Trap
❑ Other(describe):
4. Effluent Tee Filter presentY No If yes, was it cleaned? Yes E] No
CY _
5. Condition of System:
Good-,-,system operating
p
rqperly
6. System Pumped By:
-Jason Elliott 571437 --- ---
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pump!
7. Location where contents were disposed:
L
6/20/2017
'ZsVrature of Hail-, Date
Signature of Receiving Facility Date
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