HomeMy WebLinkAboutSeptic Pumping Slip - 57 CANDLESTICK ROAD 1/9/2018 'Z\ Commonwealth of Massachusetts
City/Town of North Andover
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System Pumping Record
_. Form 4 �
DEP has provided this form for use by local Boards of Health. Other farms 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 9
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 57 Candlestick Road
key to move your Address
cursor-do not North Andover MA 01845
use the return -.-- _. _.__. _.... _
key. City/Town State Zip Code
r 2. System Owner:
Michael Medeiros
_
Name ._._........._.
ream
Address(if different from location)
City/Town State Zip Code
Telephone Nurn-be r
B. Pumping Record
1. Date of Pumping ----_. .12/4/20.17 __-- 2. Quantity Pumped: 1500
_
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 operatln properly
F. 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:
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GLSD
12/4/2017
Sig ure of Hauler Date
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Signature of Receiving Facility Date
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