HomeMy WebLinkAboutSeptic Pumping Slip - 582 SHARPNERS POND ROAD 5/7/2018 RECEIVED
�LN Commonwealth of Massachusetts MAY 0 / 2018
City/Town of North Andover
TOWN OF NORTH ANDOVER
System Pumping Record HrAu'i°i DEPARTMENT
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 I System Location:
on the computer,
use only the tab 582 Sharpners Pond Road
-- -1.�- �--........................
key to move your Address
cursor-do not North Andover MA 01845-3336
use the return ............................... ................ .................
key. City/Town State Zip Code
VQ 2. System Owner:
Matthew Penny
Name
................................................
Address(if different from location)
City/Town State Zip Code
508-423-0348
Tele" -phone Number
..........................................------------
B. Pumping Record
1. Date of Pumping 4/11/2018 2. Quantity Pumped: 1500--------"—
Date Gallons
3. Type of system: Cesspool(s) Z Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes Z No If yes,was it cleaned? Yes No
5. Condition of System:
Good, system operating properly
6. System Pumped By:
Jason Elliott 571437
N�--------- --�----���---�——--�---- �1-1 1................................-
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
. ...........
7. Location where contents were disposed:
GLSD
.................................................... ........... ...........................
4/11/2018
.......................... ............................ .................. --------------
Sl`q7mr—u're of Hauler Date
Signature of Receiving Facility Date
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