HomeMy WebLinkAboutSeptic Pumping Slip - 54 STERLING LANE 1/9/2018 Commonwealth of Massachusetts
City/Town of North Andover
e
System Pumping Record
Form 4
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 54 Sterling Lane
.....
key to move your Address ___--
cursor-do not North AndoverMA 01845
use the return ....... __ ...._ ._ _................
key. City/Town State Zip Code
2. Systern Owner:
rab
Mandell
Name
Address'('if different from location)
Cltyffown State Zip Code
781-698-7379
Telephone Number
B. Pumping Record
12/22/2017 1500
1. Date of Pumping 2. Quantity Pumped: --
Datee 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
12/22/2017
eSM— e of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03106 System Pumping Record•Page 1 of 11