HomeMy WebLinkAbout- Septic Pumping Slip - 45 WINDKIST FARM ROAD 5/7/2019 Cammonwealth o Massachusetts
.n C t h
y/Town of Nort
Andover,
SystemForm 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information rust be substantially the earns as that provided here. Before using this form, check with your
local Board of Health,to determine the form they use. The System ring Record must be silubmi'tted t
the local Board of Health or other approving auth rrt within '14 days from the pumping date in
accordance with 310, CMR 15.351
1
,A.
Facility
Important:When
filling out forms System La cation:
on the computer,
5 mist Farm Road
use only the tab
key to move your Address
cursor r-do not North Andover MA 5
use thin returnkey ...
. City/Town State dip Code
tab
. System Owner:
Stephen Carta
.. m. mm
Name
mm,
Address if clifferent fr m location)
City/Town State Zip Code
® - ` " 3
Telephone Number
......:...
Pumping Record
4/22/2019 1500
1. Date f Pumping ry 2. QuantityI u��r
Date Gallons
3. 'Type of system:r Cess a l s Septic TankTight Tank El Grease Trap,
El Other(describe): �mm ....... m. .
Effluent Tee Filter present? Yes Z No If yes, was it cleared? Yes Zi No
1
5.
Condition of System.-
Good, system operating properly
6. System Pumped :
,Jason Elliott S71437
License Number
Iviester and Elliott Services LLC-DB,A Jason
Elliott Pumping,
7'. Location where contents were,disposiedl
GLSD
4/22/2019
HaulerSZOMMre of Date
n..............................ature....mm. ......,...
+ f Il e i°�in Facility Cate
t5f rm . a 03,/06 System Pumping Record rri Page 1 of 3,