HomeMy WebLinkAboutSeptic Pumping Slip - 743 FOREST STREET 6/18/2017 Commonwealth of Massachusetts
MCEIVED
City/Town of North Andover
System Pumping Record
Form 4 OWN O�-N(')R�H AW0VFR
i W-:A04 DEpAFT MEDIT
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 743 Forrest Street
key to move your Address
cursor-do not North Andover MA 01845
use the return ...........- -—-----
key. City/Town State Zip Code
2. System Owner:
John lannarone
Name
Address(if different from 1`6 c'ail o-n-) ---------......
..................
City/Town State Zip Code
978-681-6146
Telephone Number
B. Pumping Record
�6Date
11 8/?017.. 1500 —------
1. Date of Pumping Da I te 2. Quantity Pumped: Gallons
3. Type of system: El Cesspool(s) 0 Septic Tank F] Tight Tank F-1 Grease Trap
El Other(describe): ----------------
Tvi
4. Effluent Tee Filter present? Yes Lnj No If yes, was it cleaned? Yes ❑ 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
-Ell-i--o---t---t----PI-----u----m----ping
.............
7. Location where contents were disposed:
/�j ------
6/18/2017
C91 re k lauler Date
................-............ -
Signature of Receiving Facility Date
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