HomeMy WebLinkAboutSeptic Pumping Slip - 179 HAY MEADOW ROAD 7/10/2018 LN Commonwealth of Massachusetts R Ef l
- City/Town of North Andover
System Pumping Record JUL 10 018
Form 4
TOWN L�nH ani PARANDOVER
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 t
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filfing out forms 1. System Location:
on the computer,
use only the tab 179 Hay Meadow Road _
key to move your Address
cursor-do not North Andover MA 01845-2931
use the return
key. City/Town State Zip Code
2. System Owner:
George Tagarelis
Name
Address(if different from location)
City(rown State Zip Code
781-789-1735
Telephone Number
B. Pumping Record
1. Date of Pumping 61281201,8 p 1500 _
Date __. 2. Quantity Pum ed: Gallon.s
3. Type of system: ❑ Cesspool(s) 0 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 operatingproperly
6. System Pumped By:
Jason Elliott 571437
._..................... _._ _ . ._. ......__...__...._
Name vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping I
1
7. Location where contents were disposed:
GLSD
6/28/2018
Si ure of Hauler Date
........._.._... ,........................................ .......__........_... --------.......---- --
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page t of 4