HomeMy WebLinkAboutSeptic Pumping Slip - 305 BOSTON STREET 1/9/2018 C[ MDWnVea.fh of Massachusetts
City/Town of
'-0YTQVDwf North Andover
x�vx�*u� Pumping
Record
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TOYN�OFNURTHAHDUVCM
Form 4
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DEP has provided this form for use bylocal Boards ofHealth. Other forms may housed, bwi 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 Recon] must be submitted to
the |moa| Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310CyWR15351.
A. Facility Information
Important:�v
N|iout forms 1. System Location:
on the computer,
use only the tab 305 Boston Street
key mmove yuur Address
uumv,'do not
North Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
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Name
Address(if different from location)
cii-ty/Town State Zip Code
Telephone Number
B. Pumping Record
1. Oat*of Pumping 12/8/2017 2. Quantity Pumped: 1500
bateGallons
3. Type ofsystem: Fl Cesspool(s) Septic Tank F Tight Tank El Grease Trap
F1 Other(describe):
4. Effluent Tee Filter present? Yea No |fyes,was itcleaned? Yon Z No
6� Condition ofSystem:
Good, to tiproperty
8. System Pumped By:
Jason Elliott S71437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumi
7. Location where contents were disposed:
GLSD