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HomeMy WebLinkAbout- Septic Pumping Slip - 24 DEER MEADOW ROAD 2/6/2019 Commonwealth of Massachusetts iu .._ City/dawn of North Andover System Pumping Record i 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 CM 15,351. . ............_...-------- A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab 24 Deer Meadow Road key to move your Address cursor-do not North Andover MA 01845 use the return -- _.._... .. .._-_....__._.__ ........_. -- key. City/Town State Zip Code 2. System Owner: Q Gert Vente Name ream Address(if different from location) City/Town State Zip Code 248-882-8910 Telephone Number B. Pumping Record 01/18/2019 1500 1. Date of Purnping Date_._..�_.......................� 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 Pumpin 7. Location where contents were disposed: j GLSD i 01/18/2019 M' ur'of Hauler Date Signature of Receiving Facility Date t5forrn4.doc•03/06 System Pumping Record•Page 2 of 2