HomeMy WebLinkAboutSeptic Pumping Slip - 143 LIBERTY STREET 8/15/2017 Commonwealth of Massachusetts
City/Town of North Andover
IA3N:mmE System Pumping Recorsved
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 143 Liberty Street ----------------------------------------------- ----------
key to move your Address
cursor-do not North Andover MA 01845
use the return
key. City/Town State Zip Code
o2. System Owner:
Deyeso
Name
Address(if different from location)
--------------- ............
City/Town State Zip Code
978-688-2784
'o n-eNumber'"" ......
Tele—ph
B. Pumping Record
7/21/20171500
1. Date of Pumping -bafe---- 2. Quantity Pumped: Gallons
3. Type of system: El Cesspool(s) Septic Tank Tight Tank ❑ Grease Trap
n Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes r'71' No
5. Condition of System:
Good, system operating properly
6. System Pumped By:
Jason Elliott 571437
-Na me ehi
- -- -,-, - V---"cl --e"-License-,-"-,--Number
IvesterIvester and Elliott Services LLC-DBA Jason
Elliott Pumpin
7. Location where contents were disposed:
-GLSD
7/21/2017
star of Mauler Date
----------- ------------------------
Signature of Receiving Facility Date
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