HomeMy WebLinkAboutSeptic Pumping Slip - 32 PADDOCK LANE 9/11/2017 Commonwealth of Massachusetts RECEIVED
City/Town of North Andover aP
System Pumping o r
a a Form 4 T DEPS ME
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 t
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, 32 Paddock Lane
use only the tab
key to move your Address
cursor-do not North Andover MA 01845
use the return City/Town State Zip Code m
key.
2. System Owner:
JasonKuberski 1.
rain fu ---- ------ ----------------------- — --- _...
Name �
Address(if different from location)
City/Town State Zip Code
617-791-5532
Telephone Number
B.
Pumping ecor
1. Date of Pumping 8//11/2017 1500 2. Quantity Pumped: ----..-... -------
Date Gallons
3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - .........................._...._.. ...._ . ..
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes No
5. Condition of System:
Good, system operating properly
6. System Pumped By:
Jason Elliott 571437
Marne Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
8/111/2017
Si at o�H�ulerDate
Signature of Receiving Facility Date
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