HomeMy WebLinkAboutSeptic Pumping Slip - 469 BOSTON STREET 6/2/2017 Commonwealth of Massachusetts
RECEIVED
City/Town of North Andover
System Pumping Record
Form 4 Tovj 0�`NOR�H ANDOVER
HEAL71,i DEFIARTMENT'
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 469 Boston Street ................ ..........
key to move your Address
cursor-do not North Andover MA 01845-6318
use the return
key. City/Town State Zip Code
VQ 2. System Owner:
Matthew Quinlan
Name
d-iff-er"en-t-'fr'o-mlocation)"- - ---- ..........
Address(if ..............
City/Town State Zip Code
603-475-2913
Telephone Number
B. Pumping Record
6/2/2017 1500
1. Date of PumpingDate._ 2. Quantity Pumped: Gallons
3. Type of system: [j Cesspool(s) Z Septic Tank n Tight Tank n Grease Trap
F-1 Other(describe): ------ -------— -----------------
4. Effluent Tee Filter present?CY Yes El No If yes, was it cleaned?( Y Yes)EI No
-
5. Condition of System:
Good, system operating properly
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:
6/2/2017
1 0 oa-0eUH'- ler Date
Signature of Receiving Facility Date
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