HomeMy WebLinkAboutSeptic Pumping Slip - 734 FOSTER STREET 9/11/2017 Commonwealth of Massachusetts
RECEIVED
City/Town of North Andover
System Pumping Record
Form 4 Mf!t,IORMI ANDOVU�
1JEALIH DEV)ARTMENT
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 734 Foster Street
key to move your Address
cursor-do not North Andover MA 01845-1434
use the return ......
key. CityfTown State Zip Code
2. System Owner:
tab
James Clawson
Name ---------------------------------
Address(if different from location)
..................
State Zip Code
978-682-5611
Telephone Number
B. Pumping Record
1. Date of Pumping 8/29/2017 2. Quantity Pumped: 1500
Gallons
3. Type of system: ❑ Cesspool(s) Z Septic Tank n Tight Tank F-1 Grease Trap
F] Other(describe): ...........
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes No
5. Condition of System:
Good, m systeoperating properly
.................. -----------------------
6. System Pumped By:
Jason Elliott S71437
.......... ...........
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7, Location where contents were disposed:
&P—S-D,
8/29/2017
—------------------------
............................
Qi nitureLof Hauler—, Date
— --
S�inatur e-of Receiving Facility Date
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