HomeMy WebLinkAboutSeptic Pumping Slip - 43 STONECLEAVE ROAD 7/10/2019 rJOD ]DAea|fh of Massachusetts
r 'fy/T[ V[ of North Andover RECEIVED
����st���� ������K�~U��� ����K���r�| JU| 1 � �Mi8
System Pumping _ - -
Form 4
`rOWNOFNDMHANDOVER
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must besubstantially the same aethat 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 3i0CK4Ri5.351.
A, Facility Information
Important:
filling out forms 1. System Location:
on the use cm��eub� 43Sb»neobmveRoad
key mmove your Address
m,mmr-do not
North Andover MA 01845
use the return
x*y. ~',''~~^' State Zip Code
2. System Owner:
�--� Stanley U
mpert
Name
City/Town State Zip Code
978-882-3817
B. Pumping Record
6/5/2018 1500
i. Date ofPumping Date 2. Quantity Pumped: Gallons
3. Type ofvyetnm: F1 Cesspool(s) 0 Septic Tank F1 Tight Tank Fl Grease Trap
El Other(describe):
4. Effluent Tee Filter present? Yes No |fyes, was itcleaned? Yes No
5. Condition of System:
Good, system operatingproperly
8. System Pumped By:
Jason Elliott 871437
"a 'e— Vehicle License Number
Ivester and Elliott Sen/imoe LLC-DBA Jason
B|io# P �
7. Location where contents were disposed:
GLSD