HomeMy WebLinkAbout- Septic Pumping Slip - 680 FOREST STREET 9/7/2018 Commonwealth of Massachusetts
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City/Town of North Andover �:.�
d System Pumping Record .l. t4 1=N( it AND0v12l°
Form 4 DU')4RflV1G:N'
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 680 Forest Street
key to move your Address
cursor-do not North Andover MA 01845
use the return _ _. ......._._ ......._ ____— _ _..._._--
key, CityfCown State Zip Code
2. System Owner:
Martha Caso
Name
Address(if different from location)
__.... ..........._. .......-- – – —._._...._._,. --
City/Town State Zip code
978-886-0124
Telephone Number
B. Pumping Record
1. Date of Pumping 8/30/2018 2. Quantity Pumped: 1500
Date Gallons
3. Type of system: Cesspool(s) ® Septic Tank El 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 proporly
6. System Pumped By:
Jason Elliott571437
- w.
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
.......... — _._.w_ ..._ . .......
8/30/2018
aSig `rl�ure of Hauler Date
I
......
Sugnature of Receiving Facility Date
1
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