HomeMy WebLinkAboutSeptic Pumping Slip - 62 FARNUM STREET 6/16/2017 Commonwealth of Massachusetts RFCEIVED
City/Town of North Andover
0 1 f
System Pumping Record TOWN 0�-Nol< OiL)OVER
Form 4
HEALT�i 0EPAKWENT
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 62 Farnum 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:
teb
Brian Hickey ...............
Name
renrn
Address(if different from location)
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 6/16/2017 2. Quantity Pumped: .1500
flo ns"..............
Date da
3. Type of system: El Cesspool(s) E Septic Tank F] Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
Goad, 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:
GLSd
6/16/2017
'ignitLurE-of`F1au6-r --" Date
Signature
ateignature of Receiving Facility Date
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