HomeMy WebLinkAboutSeptic Pumping Slip - 120 GRANVILLE LANE 6/12/2017 ar;Cr_jNjED
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Commonwealth of Massachusetts � �
------ ------- City/Town of North Andover ON
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System Pumping Record Uj.pPATME
Form 4
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 120 Grandville Lane ....... ......
key to move your Address
cursor-do not North Andover MA 01845
use the return Cityfrown State Zip Code
key.
2. System Owner:
Maureen Hunter
Name
Tartan
Address(if different from location)
CityCrown State Zip Code
443-306-9331
Telephone
6i ho.ne I.,Number
. .
B. Pumping Record
1. Date of Pumping 6/12/2017 2. Quantity Pumped: 1500
Date Gallons
3. Type of system: El Cesspool(s) 0 Septic Tank F-1 Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
Good,_system operating er�
pi�ra......�99pjWy_ . ..............
6. System Pumped By:
-Jason Elliott 571437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
-Elliott Pumping
7. -LooAtion where contents were disposed:
.GL
_----------------.....................................
ig !9re-offl—auler Date
6/12/2017
Signature of Receiving Facility Date
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