HomeMy WebLinkAbout- Septic Pumping Slip - 1542 SALEM STREET 1/8/2019 it
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Commonwealth of Massachusetts
City/Town of North Andover
o 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 1
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 1542 Salem Street
key to move your Address
cursor-do not North Andover MA 01845-4916
use the return
key. City/Town State Zip Code
2. System Owner:
Alex Grant
Name
rsatim ,
Address(if different from location)
City/Town State Zip Code
603-566-6904
_....,- - ---------
Telephone Number
B. Pumping Record
12/31/2018 1500
Dat
1. Date of Pumping e _......_..... ..,, 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
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
12/31/2018
Si ure of Hauler Date
Signature of Receiving Facility Date
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