HomeMy WebLinkAbout- Septic Pumping Slip - 115 JOHNNY CAKE STREET 9/7/2018 L\ Commonwealth of Massachusetts =;y �`° `
-- W City/Town of North Andover SET 0 /U1
stem Pumping Record
Form 4 HEA i ii 1X,T'AwiU MENI"
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 I
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 CM R 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 115 Johnny Cake Street
key to move your Address
cursor-do not North Andover MA 01845
use the return _.._ ...... _ ...... _..�
key. City/Town State Zip Code
2. System Owner:
teb
Laura Sincerbeaux
Name
re�rn
Address(if different from location)
City/Town State Zip Code
910-988-9044
Telephone Number
B. Pumping Record
8/2/2018 1500
1. Date of Pumping -_ - 2. Quantity Pumped:
Date- 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 Elliott 571437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
8/2/2018
M'g 'r�'oi"
Hauler Date
Signature of Receiving Facility Date
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