HomeMy WebLinkAboutSeptic Pumping Slip - 926 FOREST STREET 5/2/2017 Commonwealth of Massachusetts RECEIVED
City/Town of North Andover ?
Sys
ovER tem Pumping Record TOVVt,i Iq()�+ AND
Form 4 HVAUil[)UDARTMEW
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 926 Forest Street ............
key to move your Address
cursor-do not North Andover MA 01845-3324
use the return
key. City/Town State Zip Code
2. System Owner:
John Longueil
Name
ratan
..............
Address(if different from location)
..........
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
5/2/2017 1000
1. Date of Pumping -bai.e....... 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) M Septic Tank El Tight Tank M Grease Trap
0 Other(describe): ----------
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
Good, system o�aTtiqq properly
----—------
6. System Pumped By:
Jason Elliott 571437
Name -Vehicle LicenseNumber
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD,
5/2/2017
Date
Signature of Receiving Facility Date
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