HomeMy WebLinkAboutSeptic Pumping Slip - 110 DUNCAN DRIVE 7/10/2018 Commonwealth of Massachusetts RECEIVED
xCity/Town of North Andover
System Pumping Record
Form 4 rom 0I-'NOR i ,I ANDOVER
W,,�TALV[i i U1Ai'1 MEET
DEP has provided this form for use by local Boards of Health. Other farms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your 1
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 110 Duncan Drive
key to move your Address _..._
cursor-do not North AndoverMA 01845-2231
use the return _ _..... _.,_....__ ......_.....
key. City/Town State Zip Code
2. System Owner:
rob
Linda Cahill
Name
renin
Address(if different from location)
_,.. .. _............. ---__ _.. ..,_. _....._.......
City/Town State Zip Code
978-258-0199
.._............................................._ –
Telephone Number
B. Pumping Record
6/5/2018 1500
1. Date of Pumping -- — 2, Quantity Pumped:
Crate 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 Elliott571437
_._a......_ .._..,...._..__._,..__
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
6/5/2018
Si ure of Hauler 1.Date
Signature of Receiving Facility Date
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