HomeMy WebLinkAbout- Septic Pumping Slip - 155 BOSTON STREET 11/13/2018 jVr
,C-\ Commonwealth of Massachusettsrr
City/Town of North Andover IV 1 U101a
System Pumping Record O R, ft
Form 4 HEAjjjq¢ r �
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.
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1
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 155 Boston Street
key to move your Address
cursor-do not North Andover MA 01845
use the return _... .......-__ --..._._._. ............. ...._._. _........ _ _.......
key. Cityfrown State Zip Code
2. System Owner:
Allen
Name
ram
Address(if different from location}
City/Town Sta#e Zip Code
508-479-4001
Telephone Number
m..........._...._..._.._..._,,..,,,,,,.._-_--......._.__a...... - — ...-_---------- .............. .......
B. Pumping Record
1. Date of Pumping 10/23/2018 2, Quantity Pumped: 1500
Date Gallons
3. Type of system: ❑ Cesspool(s) Z 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
Narne Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
10/23/2018 t
Sig ure of Hauler Date t
Signature of Receiving Facility Date
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