HomeMy WebLinkAbout- Septic Pumping Slip - 255 OLD CART WAY 10/9/2018 I li;
Commonwealth of Massachusetts (A 11, 0 9 r 1
City/Town of North Andover
- System Pumping Record
- 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 255 Old Cart Way
key to move your Address _-._...� .�. . _. .��.._�. ___.. ...._.. __
cursor-do not North Andover MA 01€345
use the return City/Town ---- ------ State Zip Code —
key.
2. System Owner:
r�
Jennifer Thorn
Name
faaan
Address(if different from location)
........ ..... ..
City/Town State Zip Code
617-828-1120
Telephone Nurnber
B. Pumping Record
9/28/2018 1500
1. Date of Pumping _ . 2. Quantity Pumped: Gallo_.n...._s_
Date
3. Type of system: ❑ Cesspool(s) 0 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
__....w ......___.._. ..__._._ ...____.._ . _....w _— ___.._ __.._...__..__.____._._.._.__._... . ......w .___.__._...._
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
9/28/2018
Sig ure of Hauler Date
Signature of Receiving Facility Date
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