HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 524 JOHNSON STREET 7/13/2020 Commonwealth of Massachusetts RECEIVED
City/Town of North Andover JUL 13 2020
a System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
'LAM
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 524 Johnson Street - -
key to move your Address
cursor-do not North Andover MA 01845
use the return key. City/Town State Zip Code
�1 2. System Owner:
V�
Fortin
Name --- - - --- -. -
seem
Address(if different from location)
City/Town State Zip Code
978-688-2096
Telephone Number
B. Pumping Record
6/23/2020 1000
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
_ 6/23/20.2_0_
Sig ure of Hauler Date
Signature of Receiving Facility Date
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