HomeMy WebLinkAboutSeptic Pumping Slip - 42 OLD CART WAY 6/29/2017 Commonwealth of Massachusetts RECEIVED
City/Town of North Andover
System Pumping Record
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 42 Old Cart Way
key to move your Address
cursor-do not North Andover MA 01845-6342
use the return I......... ..........
key. City/Town State Zip Code
2. System Owner:
Peb
Katie
atie Kennedy
-
----Name
ratwn
- � ' i " ---- - --- —-------_
Address(if from location) . ......
City/Town State Zip Code
430-206-6539
Telephone Number
B. Pumping Record
5/24/2017 1500 ate
1. Date of Pumping 2. Quantity Pumped: Gallons ---------------------
3. Type of system: Ej Cesspool(s) 0 Septic Tank El Tight Tank 0 Grease Trap
F1 Other(describe): —------ ..........
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
Good, system oparAairj 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:
5/24/2017
.....................
Uirg u e of Hauler Date
Signature of Receiving Facility Date
t5form4.doc-03/06 System Pumping Record 4 Page 1 of 22