HomeMy WebLinkAboutSeptic Pumping Slip - 125 CROSSBOW LANE 9/11/2017 Commonwealth of Massachusetts RECEIVED
p City/Town of North Andover 0 ,112017
VA
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 125 Crossbow Lane
key to move your Address
cursor-do not North Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
Sean Richard
Name
reaan
Address(if different from location)
-State..__..
S-tif-e--.. Zip Code
860-733-5527
I.. ...........-
Telephone. . . Number
. .. .. -.. ..........- -----------------------------
B. Pumping Record
8/6/2017 1500
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank F1 Grease Trap
n 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
-Nam"eVehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
,GL8D--, -
8/6/2017
Si ature-61'Hauler Date
Signature of Receiving Facility Date
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