HomeMy WebLinkAboutSeptic Pumping Slip - 1055 FOREST STREET 11/17/2017 |
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Commonwealth of Massachusetts
'N'8V 16 0i7
City/Town of North Andover
T��NOF�ORTNANQOVER
������00 ���0Np~ng Record DEP
AP,
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
|000| Board of Health to determine the form they use. The System Pumping Raoonj must bosubmitted to
the local Board of Health urother approving authority within 14days from the pumping date in
accordance with 310CWR 15.351.
A~ Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 1055 Forest Street
key mmove your Address
oumu,'do not
North Andover MA 01845
use the return
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2. System Owner:
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David Smart
Address(if different from locat0�
City/Town State Zip Code
078-882-5371
B. Pumping Record
10/24/2017 1500
1. Da��ofPumping - 2. Quantity Pumped.
Gallons
3. Type ofsystem: [l Cesspool(s) [K Septic Tank [l Tight Tank Fl Grease Trap
L1 Other(describe):
4. Effluent Tee Filter present? Yea No ]/yes, was itcleaned? Yea No
S. Condition of System:
Good system tiproperly
6. System Pumped By:
Jason Elliott S71437
Vehicte License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD