HomeMy WebLinkAboutSeptic Pumping Slip - 207 FARNUM STREET 11/17/2017 Commonwealth of Massachusetts
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City/Town of North Andover ';
System Pumping Record TONgO NU,�UH ANI)OVER
Form 4 HEALD,i DEFIARTNAENI'
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 t
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 207 Famum Street
key to move your Address
cursor-do not North Andover MA01845
use the return
key. Cityfrown Stato Zip Code
2. System Owner:
rab
Mixon
Name
Address(if different from location)
Cityfrown State Zip Code
078-790-5462
___.le_._phon_.__.e...Nu_..__.mber
....___ __...
Te
B. Pumping Record
10/10/20171500
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 ® No
5. Condition of System:
Good, system operating properly
6. System Pumped By:
Jason Elliott 571437
.. .._..... .. .....__..__...._. ....._. _. ....._.
Name Vehicie license Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
10/10/2017
Si ure of Flauler Date r
.......- ..._.- ._ .._..._ _..._ _..
Signature of Receiving Facility Date
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