HomeMy WebLinkAboutSeptic Pumping Slip - 325 SUMMER STREET 8/6/2018 Commonwealth of Massachusetts RECEIVED
City/Town of North Andover
-ioM OF�'JORJ'��0J)OVER
System Pumping Record
R11W-DiT
Form 4 EALTH 001A
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 325 Summer Street
key to move your Address
cursor-do not North Andover MA 01845
use the return
key. City/Town State Zip Code
VQ 2. System Owner:
Paul Diorio
Name
ream
'Address(if different from location) ................
---------------- State
........... ...........—
City/Town State Zip Code
978-886-1141
Telephone-N-umber
------------------------------ ------
B. Pumping Record
1. Date of Pumping 7/16/2018 2. Quantity Pumped: 1000
-ba ie'' '' '"—— Gallons
3. Type of system: El Cesspool(s) Septic Tank ❑ Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? Yes Z 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
----------------------- -- ------------------------
7/16/2018
...........
Signature—o"f—'Receiving FacilityDate
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