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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 64 WHITE BIRCH LANE 7/13/2020 ICN Commonwealth of Massachusetts RECEIVED City/Town of North Andover JUL 13 2020 System Pumping Record TOWN OF NORTH ANDOVER iU^M 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 64 White Birch Lane key to move your Address cursor-do not North Andover MA 01845-1112 use the return - --- - -— key. City/Town State Zip Code m 2. System Owner: Kendra Laverty _ Name - nem Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 6/23/2020 _ 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 Wester and Elliott Services LLC-DBA Jason Elliott Pumping 7. Location where contents were disposed: GLSD 6/23/2020 Mg .e-of Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 12