HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 67 ROCKY BROOK ROAD 12/5/2019 Commonwealth of Massachusetts RECEIVED
w City/Town of North Andover
System Pumping Record DEC 05 2019
Form 4 TOWN OF NORTH ANDOVER
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 67 Rocky Brook 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:
VILA Jay Huapaya
Name - - -
�n
Address(if different from location)
City/Town State Zip Code
978-697-1842
Telephone Number
B. Pumping Record
1. Date of Pumping 11/14/2019 2. Quantity Pumped: 2000
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
11/14/2019
Sig ure of Hauler Date
Signature of Receiving Facility Date
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