HomeMy WebLinkAboutSeptic Pumping Slip - 967 JOHNSON STREET 6/16/2017 Commonwealth of Massachusetts RECEIVED
City/Town of North Andover
System Pumping Recorx.
d
Form 4 �IEALDA DL'F'1ARTMEt4T
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 967 Johnson Street
key to move your Address
cursor-do not North Andover MA 01845-5527
use the return
key. City/Town State Zip Code
VQ 2. System Owner:
James Pacheco
Name
Address-(if d'iff"e"r"e"'-n
k from location)
Cityf'rown Skake Zip Code
978-314-2114
Telephone Number
B. Pumping Record
1. Date of Pumping 6/16/2017 2. Quantity Pumped: 1500
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
F1 Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
Good,
.Stem_.operatin_q_pro
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:
6/16/2017
............
ig atur fauler
Date
Signature of Receiving Facility Date
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