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HomeMy WebLinkAbout- Septic Pumping Slip - 1248 SALEM STREET 12/6/2018 Commonwealth of Massachusettss !) M _ City/Town of North Andover t ��i SystemPumping Record r ' e 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. .__e........._...-- ... ------------------------ ---------- A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab 1248 Salem Street key to move your Address -_- cursor-do not North Andover MA 01845-4910 use the return -_— _ _.._._.._.. ... . _..._.... -_. key. City/Town State Zip Code 2. System Owner: r�r Laura D'rBlasl .... ............._.__._-- Name Address if different from location) City/Town State Zip Code 978-689-9355 Telephone Number —_ - --------------------- --- B. Pumping Record 11/7/201$ 1500 1. Date of Pumping pate _ .._.._ _....... 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 i 5. Condition of System: Good, system operating roperly 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 11/7/2018 Si ure of Hauler Date _... _---- ..... Signature of Receiving Facility Date t5form4.doc-03/06 System Pumping Record•Page 1 of 7