HomeMy WebLinkAbout- Septic Pumping Slip - 56 BRIDGES LANE 11/13/2018 Commonwealth of Massachusetts RECEIVED
City/Town of North Andover
NOV 13 ?0
System Pumping Record
'TOWN OF NOR ri-i�,rlwV[`R
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.
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A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 56 Bridges Lane
key to move your Address
cursor-do not North Andover MA 01845-2225
use the return ----------
key. City/Town State Zip Code
2. System Owner:
Jeffrey Morgenthaler
Name
anxn
mdre-s s'Of different from location)
City/Town State Zip Code
978-376-5555
Telephone Number
B. Pumping Record
1. Date of Pumping 10/9/2018 2. Quantity Pumped: 1500
Date Gallons
........ ......
3. Type of system: F1 Cesspool(s) 0 Septic Tank El Tight Tank El Grease Trap
n 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:
GLSID
10/9/2018
�Si,�J6_�ure of Hauler Date
..
Signature of Receiving Facility Date,
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