HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 17 LACY STREET 11/12/2019 RECEIVED
Commonwealth of Massachusetts
City/Town of North Andover NOV 1 2 201y
W YVN OF NORTH ANDUVER TQ
System Pumping Record HEALTH DEPARTMENT
Form 4
M
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 17 Lacy Street
key to move your Address
cursor-do not North Andover MA_ 01845
use the return City/Town State Zip Code
key.
2. System Owner:
rt
Rebecca Bailey
Name
- - - - - - ---------- --
Address(if different from location)
City/Town State Zip Code
781-572-7644
Telephone Number
B. Pumping Record
10/28/2019 1500
1. Date of Pumping 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 Pumping
7. Location where contents were disposed:
GLSD
_ 10/28/_2.019
Si`g'117rulre of Hauler Date
Signature of Receiving Facility Date
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