HomeMy WebLinkAboutSeptic Pumping Slip - 229 GRAY STREET 11/17/2017 Z, Commonwealth of Massachusetts RECEIVED
City/Town of North Andover d��� '` ` �
- System Pumping Record 'rOWNLlFNOR111ANDOVER
_-- Form 4 HLAMi DEP RMENT
DEP has provided this form for use by local Boards of Health. Cather 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.
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A. Facility Information
Important:When
filling out forms 1, System Location:
on the computer,
use only the tab 229 Gray Street
key to move your Address
cursor-do not North AndoverMA 01845
use the return .____..._..__ ....._ -_._
key. Cityf6own State Zip Code
VQ 2. System Owner:
Jason DiPrimo
Name
ream
Address(if different from location)
City/Town State - Zip Code
978-902-3027
Telephone Number
B. Pumping Record
10/3/2017 1500
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 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
10/3/2017
Si ure of Hauler ___ pate
Signature of Receiving Facility Date
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