HomeMy WebLinkAboutSeptic Pumping Slip - 148 CROSSBOW LANE 5/5/2017 Commonwealth of Massachusetts RECEIVED
City/Town of North Andover
System Pumping Record
Tow,ol:NOP�14 P'tl[)OVER
Form 4 HrACTH 6L'��j�jIAENT
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 148 Crossbow Lane
key to move your Address
cursor-do not North Andover MA 01845-3038
use the return
key. CitylTown State Zip Code
2. System Owner:
Andrew Cournoyer
Name
rsnvn
Address(if different from location)
-------------------------
CityrFown State Zip Code
339-221-4058
Telephone
6ie ph on e Number
B. Pumping Record
1. Date of Pumping .5/5/2017 2. Quantity Pumped: 1500
Date Gallons
3. Type of system: F-1 Cesspool(s) Z Septic Tank n Tight Tank F-1 Grease Trap
n Other(describe): -------
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes No
5. Condition of System:
Good, system operatin roptqy
6. System Pumped By:
Jason Elliott 571437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
..Elliott Pqm ig,
...p q._
7. Location where contents were disposed:
D
5/5/2017
nna ure of Hauler Date
Signature of Receiving Facility Date
t5form4.doc-03106 System Pumping Record-Page 1 of 22