HomeMy WebLinkAboutSeptic Pumping Slip - 526 WINTER STREET 8/15/2017 Commonwealth of Massachusetts
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 526 Winter Street
key to move your Address
cursor-do not North AndoverMA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
Akison Kincade
Name
Address(if different from location)
Cityrrown State Zip Code
617-230-5912
Telephone
iipiione Number
B. Pumping Record
7/19/2017 1500
1. Date of Pumping Date.te 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank 0 Tight Tank El Grease Trap
El Other(describe): ----------
4. Effluent Tee Filter presentE
Des El No If yes, was it cleaned?(Y Ye'-
s F-1 No
5. Condition of System:
Good, system operatingproperly.._......_..._
6. System Pumped By:
Jason Elliott 571437
I...............................
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
.GLSD
7/19/2017
'4i�gnature, a ier Date
Signature of Receiving Facility Date
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