HomeMy WebLinkAboutSeptic Pumping Slip - 35 EVERGREEN DRIVE 9/11/2017 Commonwealth oI
f Massachusetts RECEVED
City/Town of North Andover SIP 112017
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 35_Everqreen Drive
key to move your Address
cursor-do not North Andover MA 01845
use the return ......................
key. Ci /Town State Zip Code
2. System Owner:
ren
Sandra Dinush
Name
Address(if different from location)
i
.......................I..............................................-----------—------ .........
t ................-
own State Zip Code
978-376-6777
Telephone Number
B. Pumping Record
1. Date of Pumping 8/4/2017 .................. 2. Quantity Pumped: 1500
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
R 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 S71437
-V"-e""h--ic-'I"e--Licens'e---N--u--m---be-r-----------------_a_._.__...
-------------------------------
Name
Ivester and Elliott Services LLC-DBA Jason
ElliottPumping-------------------------- ..........................................
7. Location where contents were disposed:
GLSD ------------------------------------------- -----------
8/4/2017
U re". Date
Signature of Receiving Facility Date
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