HomeMy WebLinkAbout- Septic Pumping Slip - 224 HILLSIDE ROAD 12/6/2018 Commonwealth of Massachusetts i
City/Town ��� � f'
stem PumpingNorth Record
Y �Andover
i f
S
-- Form 4 '�x '� .t
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the J
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.
__.............. - ......_.. _...� _m �._ ------------------
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 247 Hillside Road
key to move your Address
cursor-do not North Andover MA 01845
use the return _..__.._._. .. .. _... ____.... __._..... __.
key. CitylTow n State Zip Code
2. System Owner:
rr5
Laberce
Name
Faun
Address(if different from location)
CitylTown State Zip Code
603-494-1026
Telephone Number
B. Pumping Record
11/812018 1500
1. Date of Pumping 2. Quantity Pumped: _...... .... ......_ .. ......._..........
Date Gallons
3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): __.._._.__....__.... .__w_.._ . ._.... .... .....
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:
GLSD
11/8/2018
Si ure of Hauler Date
_..........._.,_.. _ ........................ -._ .........................
Signature of Receiving Facility Date
t5form4.doc•03106 System Pumping Record•Page 1 of 7