HomeMy WebLinkAboutSeptic Pumping Slip - 99 OGUNQUIT ROAD 11/17/2017 RECEIVED
Commonwealth of Massachusetts
City/Town of Forth Andover
- ° System Pumping Record LT ANDOVER
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.
i
1
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 99 Ogunquit Road
-- -- - _,.._ ._.
key to move your Address
cursor-do not North AndoverMA 01845-1470
use the return
key. City/Town State Zip Code
r�
2. System Owner:
Ali Mandalinci
1111._ _....... __ 1111. 1111_ 1111.
Name ___..._..__.........
ream
_ _. 1111. .. _..._....._..__.
Address(if different from location)
- 11.11_._. _.... 1 111 1111.,
CityiTown State Zip Code
978-208-8120
Telephone NumberB. Pumping Record
10/20/2017 1500
1. Date of Pumping -date - 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ® Septic Tank Q Tight Tank ❑ Grease Trap
® 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
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD `
10/20/2017
11-11 1111-_.
Si ure of Mauler Date
1111 .... ._.__._,_ .. _ 1111 1111-...... .._....._
Signature of Receiving Facility Dat1111__e
1
t5form4.doc•03/06 System Pumping Record-Page 1 of 11