HomeMy WebLinkAboutSeptic Pumping Slip - 275 HAY MEADOW ROAD 5/7/2018 Commonwealth of Massachusetts RECEIVED
u City/Town of North Andover �110" 0 20��
System Pumping Record TOWNOFtiOKT`I AWOV ��
Form 4 I,E L�j 4 DEPART NNS°
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 1.4 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 275 Hay Meadow Road
_. _
key to move your Address
cursor-do not North Andover MA 01845-4946
use the return ___...... _.. .. _ _..._ .._.... ._. ... _--
key, City/Town State .Zip Code
2. System Owner:
Benjamin Woodford
Name
rnnm
Address(if different from location)
City/Town State Zip Code
978-655-4946
Telephone Number
_,._- _.---------------------------------------------.__-----------_._.__
B. Pumping Record
4/30/2018 1500
1. Date of Pumping Date 2. Quantity Pumped: 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:
Field is saturated, system needs inspection
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
4/30/2018
eSigure of Hauler Date
..__.._ -
.m......._ .....
Signature of Receiving Facility Date
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