HomeMy WebLinkAboutSeptic Pumping Slip - 585 SHARPNERS POND ROAD 11/17/2017 RECEIVED
Commonwealth of Massachusetts 0 17
ANDOVER
City/Town of North Andover w l i-1 N OF NOEPA
System Pumping Record
�¢ Form 4
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 535 Sharpners Pond Road
key to move your Address _.._.....__
cursor-do not North Andover MA01$45-3335
use the return
key. City/Town State Zip Code
ren
2. System Owner:
Joshua Ledeen
Name
Address(if different from location)
City/Town State Zip Code
617-733-5574
Telephone Number
B. Pumping Record
10/20/20171500
1. Date of Pumping --_._.-..__._..______..._..._.._.....___. ._ 2. Quantity Pumped: --- - ---- —
Date Gallons
3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ® No If yes, was it cleaned? Yes ® Na
5. Condition of System:
Good, system operating properly
6. System Pumped By:
Jason Elliott 571437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed: j
GLSD
l
10/20/2017
Si ure of Hauler Date
I
_ ....... ......... —__.--- . -.. .._ ........ - _ _...., _ _......_. ,._.._... __.. j
Signature of Receiving Facility Date
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