HomeMy WebLinkAboutSeptic Pumping Slip - 450 FOSTER STREET 9/11/2017 Commonwealth of Massachusetts RECEIVED
City/Town of North Andover SIP 11 12017
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
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 450 Foster Street
. . ..........................
key to move your Address
cursor-do not North AndoverMA 01845
key.
use the return City/Town State—------------------- ------------ Zip Code
2. System Owner:
Thomas Lang
Name
Address(if different from location)
----------------------------- ----------
City[Town State Zip Code
978-685-8379
Telephone Number
B. Pumping Record
8/29/20171000
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: El Cesspool(s) Septic Tank [:1 Tight Tank F-1 Grease Trap
El 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 ElliottS71437
............ ................. ............ .. .
............ ........
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
-Elliott Pumping
7. Location where contents were disposed:
RLSb —---------------------------------------- -----------
8/29/2017
..................
Si t�+re oft Rifer
Date
—----------
Signature of Receiving Facility Date
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