HomeMy WebLinkAboutSeptic Pumping Slip - 13 LACONIA CIRCLE 5/5/2017 RECEIVED
Commonwealth of Massachusetts
City/Town of North Andover
TOWN(y��qUk��A ANDOVM
System Pumping Record �jEACTH 00"AR"WENT
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 13 Laconia Circle ——--—---------------------
key to move your Address
cursor-do not North AndoverMA 01845-3304
use the return ..................
key. City/Town State Zip Code
2. System Owner:
James Prendergast
----------
Name
Address(if different from location)
City/Town -"t Zip Code
Telephone Number
B. Pumping Record
5/5/2017 1500
1. Date of Pumping 2. Quantity Pumped:
bate Ions
& Type of system: F-1 Cesspool(s) Z Septic Tank [:1 Tight Tank F] Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? Yes rvr' No If yes, was it cleaned? Yes ❑ No
LA
5. Condition of System:
Good, system operatingproperly
..........
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:
GL
D —---------—---------- ................. .................
--
.....-----------
�❑
5/5/2017
---------------------------------
'H'au
gnat 4i Date
------------ -—-------------------
Signature of Receiving Facility Date
t5form4.doc-03106 System Pumping Record-Page 1 of 22