HomeMy WebLinkAboutSeptic Pumping Slip - 314 BOSTON STREET 10/17/2017Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
REC
1VE
I •
TOWN OF NORNi ANDOVER
DEpaamENT
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 314 Boston Street
key to move your Address
cursor - do not
use the return
key
North Andover
MA 01845-6344
City/Town State Zip Code
2. System Owner:
Christopher Marshall
Name
Address (if different from Iocation)
City/Town
State Zip Code
978-686-6106
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system: L Cesspool(s) i4 Septic Tank ID Tight Tank Grease Trap
11] Other (describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes No
5. Condition of System:
Good, system operating properly
1500
9/7/2017
Date 2. Quantity Pumped:
6. System Pumped By:
Jason Elliott
Name
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7, Location where contents were disposed:
GLSD
ure of Hauler
S71437
Vehicle License Number
9/7/2017
Date
Signature of Receiving Facility Date
Gallons
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