HomeMy WebLinkAboutSeptic Pumping Slip - 222 BRADFORD STREET 8/15/2017 IL
Commonwealth of Massachusetts
City/Town of North Andover
mm gym. 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 222 Bradford Street
key to move your Address
cursor-do not North AndoverMA 01
use the return - -
key. City/Town State Zip Code
VQ 2. System Owner:
00� Kevin Kennedy
Name
Address(if different from location)
City/Town State Zip Code
f6ieph`one Number umb er
B. Pumping Record
7/21/20171500
1. Date of Pumping ate 2. Quantity Pumped: Gallons
3. Type of system: F-1 Cesspool(s) Z Septic Tank El Tight Tank El Grease Trap
F1 Other(describe): ----------------------------------------- - -_------- ----- -----------
4. Effluent Tee Filter present? Yes IN No If yes, was it cleaned? Yes Ur No
5, Condition of System:
Good, system operating 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:
GLS-D,.
7/2112017
----------
j natur of Hauler Date
Signature of Receiving Facility Date
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