HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 734 FOSTER STREET 9/18/2019 LLD
1�nN Commonwealth of Massachusetts SEP 1 0 2019
W City/Town of North Andover TOWN OF NORTH ANDOVER
System Pumping Record HEALTH DEPARTMENT
M 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 734 Foster Street _
key to move your Address
------- -- ---
cursor-do not North Andover _ MA _ 01845-1434
use the return key. City/Town State Zip Code
m
2. System Owner:
James Clawson
-- -- ------
Name
seem
Address(if different from location)
City/Town State Zip Code
978-682-5611
Telephone Number
B. Pumping Record
1. Date of Pumping 8/6/2019 --- 2. Quantity Pumped: 1500
Date 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
8/6/2019
Mg 're of Hauler Date
Signature of Receiving Facility Date
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