HomeMy WebLinkAboutSeptic Pumping Slip - 24 PATTON LANE 6/6/2018 RECEIVED Commonwealth of Massachusetts JUN 0 ,1,j ?()18 City/Town of North Andover -- a System Pumping Record i, c� ffrMff 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 24 Patton Lane key to move your Address cursor-do not North AndoverMA 01845-4925 use the return – .-.........__. ....... key. City/Town State Zip Code 2. System Owner: Q Richard Oconnell Name Address(If different from location) — ----------- City/Town --______.City/Town State Zip Code Telephone Number B. Pumping Record e - 1. Date of Pumping518/201€3_.__......__.-.---_........__--....-..__-_-- 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 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 5/i3/2018 Si ure of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record Page 1 of 5