HomeMy WebLinkAboutSeptic Pumping Slip - 60 RALEIGH TAVERN LANE 11/17/2017 Commonwealth of Massachusetts
City/Town of North Andover UU I
System Pumping Record TOWN OF11 R'r6-ANDOVER
Form 4 HEALTH DEPMTMEE'f
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 60 Raleigh Tavern Road
key to move your Address _..
cursor-do not North Andover _ MA 01845
use the return
key. City[Town State Zip Code
2. System Owner:
rah
Robert Rogers
Name
rerun
Address(if different from location)
CifWf6wn State Zip Code
978-815-9284
Telephone Number
B. Pumping Record
1. bate of Pumping Date 10/3/2017 2• Quantity Pumped: 1500
Gallons
3, Type of system: ❑ Cesspool(s) N Septic rank ❑ Tight Tank ❑ Grease Trap
❑
Other(describe):
4. Effluent Tee Filter present? X Yes ® No If yes, was it cleaned? X 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
Sig ure of Hauler Date
Signature of Receiving Facility Date
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