HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 106 ROCKY BROOK ROAD 12/9/2020 RECEIVED
If Commonwealth of Massachusetts pEC p 0 2020
W City/Town of North Andover
System Pumping Record TOALTNVJ UE?R MENT NDOVER
Form 4
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 106 Rocky Brook Road
key to move your Address
cursor-do not North Andover _ _ MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
Aleks_andr Shneyderman
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 11/12/2020 - 2. Quantity Pumped: 1500
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
11/12/2020
Si ure of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 9