HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2001 SALEM STREET 11/20/2020 RECEIVED
-<L\ Commonwealth of Massachusetts
W City/Town of North AndoverWN OF NORTH NOV 2 0 2020
System Pumping Record TO 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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 2001 Salem Street
key to move your Address
cursor-do not North Andover MA _ 01845 _
use the return --- --
key.
City/Town State Zip Code
V1 2. System Owner:
m
Erin Blanchard
Name _ - -_
Isom
Address(if different from location)
City/Town State Zip Code
802-318-5715
Telephone Number
B. Pumping Record
1500
1. Date of Pumping Date 020 2. Quantity Pumped. Gallons
ns
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
10/9/2020
Sig ure of Hauler Date
Signature of Receiving Facility Date
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