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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 222 BRADFORD STREET 8/8/2019 i i I 'L\ Commonwealth of Massachusetts RECEIVED _ W City/Town of North Andover AUG 0 ?_0�� System Pumping Record TOWN OFN©RTHANDOVER Form 4 HEALTH DEPARTMENT 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 222 Bradford Street key to move your Address cursor-do not North Andover MA 01845-1108 use the return City/Town State Zip Code key. t� 2. System Owner: Kevin Kennedy Name 2asn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 7/23/2019 1500 j 1. Date of Pumping Date 2• Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap I ❑ 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: j Jason Elliott S71437 j Name Vehicle License Number Ivester and Elliott Services LLC-DBA Jason Elliott Pumping 7. Location where contents were disposed: i GLSD 7/23/2019 Sig ure of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 6