HomeMy WebLinkAbout- Septic Pumping Slip - 101 BRIDGES LANE 12/6/2018 Commonwealth of Massachusetts UMIN
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� t/
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 I
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 101 Bridges Lane
key to move your Address
cursor-do not North andover MA 01845-2220
use the return _. ..... ........._.. _-..._ _ .. ......_......__
key. City/Town State Zip Code
Q2. System Owner:
Stephen Cammarata
Name
reaerr
Address(if different from location)
___..... ......_.,_ _ .. .... __
City/Town state Zip Cade
617-913-1726
Telephone Number
B. Pumping Record
11/12/2018 1500
1. Date of Pumping 2. Quantity Pumped: ---_.._.. _...._. .....
Date 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
1
6. System Pumped By: I
Jason Elliott S71437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping I_.._...........__........ _
7. Location where contents were disposed:
GLSD
11/12/2018
_._......
eS, u,e of Hauler Date
......... . .....— ....._. .............._
Signature of Receiving Facility Date
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