HomeMy WebLinkAbout- Septic Pumping Slip - 703 MIDDLETON ROAD 12/6/2018 Commonwealth of Massachusetts
w 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
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
Important:when
filling out forms 1. System Location:
on the computer,
use only the tab 703 Middleton Road
................. ..._... _........ .... . .......
key to move your Address
cursor-do not North Andover MA 01845-6341
use the return �....._.__. _ _.............._ __.__ _..._......
key. City/Town State Zip Code
2. System Owner:
rah
Hana Deroche
Name
renen
Address(if different from location)
City/Town State Zip Code
978-337-8547
Telephone Number
B. Pumping Record
11/9/2018 1000
Date Gallo
1. Date of Pumping _...........__..... 2. Quantity Pumped: In n s.. _.._-
3. Type of system: ❑ Cesspool(s) ® Septic Tank n Tight Tank ❑ Grease Trap
❑ Other(describe): . _...._.._
4. Effluent Tee Filter present? Yes ® No If yes, was it cleaned? Yes ® No
5. Condition of System: t
Good, system operating properly
6. System Pumped By: 1
Jason Elliott S71437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
_.
Elliott Pumping...... .....__ __ ..... ,
7. Location where contents were disposed:
GLSD
11/9/2018
Si ure of Hauler Date
Signature of Receiving Facility Date
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