HomeMy WebLinkAboutSeptic Pumping Slip - 151 CANDLESTICK ROAD 10/17/2017Important: When
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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
TOWN OF NORTH ANDOVER
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
1. System Location:
151 Candlestick Road
Address
North Andover
City/Town
2. System Owner:
Michelle Delellis
Name
Address (if different from location)
City/Town
MA
State
01845
Zip Code
State
617-794-7211
Zip Code
Telephone Number
B. Pumping Record
9/7/2017
1. Date of Pumping 2. Quantity Pumped:
Date
1000
Gallons
3. Type of system: 0 Cesspool(s) i4 Septic Tank [I] Tight Tank 0 Grease Trap
Other (describe):
4. Effluent Tee Filter present? Yes E No If yes, was it cleaned? Yes No
5. Condition of System:
Good, system operating properly
6. System Pumped By:
Jason Elliott
Name
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
Sig ure of Hauler
S71437
Vehicle License Number
Signature of Receiving Facility
9/7/2017
Date
Date
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