HomeMy WebLinkAboutSeptic Pumping Slip - 414 FOSTER STREET 7/10/2018 I , Commonwealth of Massachusetts RECEIVED
City/Town oorth Andover
M
System Pumping Record ° RFNRRRI
NCKWI:R
Form 4 A � "WEN
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 414 Foster Street
key to move your Address
cursor-do not North Andover MA 018_45
use the return
key. City/Town — State Zip Cade
VQ
2. System Owner:
Jason Harding
Name
ransn
Address(if different from location)
City/Town State Zip Code
781-640-3927
Telephone Number
B. Pumping Record
6/26/2018 1000
1. Date of PumpingDate Gallons
2. Quantity Pumped: .................
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 ® Na
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 J
7. Location where contents were disposed: j
GLSD
R)- 612612018
Sig Bare of Hauler .Date
Signature of Receiving Facility Date
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