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HomeMy WebLinkAbout- Septic Pumping Slip - 21 EVERGREEN DRIVE 10/9/2018 _........ �..,.. Commonwealth of Massachusetts d d("e 3 0 9 ?0'i w : _ City/Town of North Andover r,Cii7C"�"�"k�h� System Pumping Record II �,i.iiii�i.���aDiU ii� Form 4 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 21 Evergreen Drive key to move your Address cursor-do not North Andover MA 01845-6001 use the return City[Fown State Zip code key. 2. System Owner: Paul Davis Narne ream Address(if different frorn location) _...... ---_.. .._......._.._.. ......... Citp own State Zip Code 978-828-7977 ... --__ _...... _ ___ Telephone Number B. Pumping Record 9/24/2018 1500 1. Date of Pumping Date 2. Quantity Pumped: 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 S71437 _ Name Vehicle License Number Ivester and Elliott Services LLC-DBA Jason Elliott Pumping 7. Location where contents were disposed: GLSD 9/24/2018 Si uro of Haulor Date Signature of Receiving Facility Date t5fonn4.doc•03/06 System Pumping Record•Page 1 of 14