HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 49 WINDSOR LANE 12/9/2020 Commonwealth of Massachusetts RECEIVED
W City/Town of North Andover SEC 9 20Z0
System Pumping Record
TOWN OF NOR,H ANVEit
MEW
Form 4 HFPOH 6F0,9T
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 49 Windsor Lane
key to move your Address
cursor-do not North Andover MA 01845
use the return — -- —- - ----
key.
City/Town State Zip Code
VQ 2. System Owner:
m
Kenneth Vertullo
— - --
Name
nun
Address(if different from location)
City/Town State Zip Code
617-438-6600
Telephone Number
B. Pumping Record
11/12/2020 1500
1. Date of Pumping pate — 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
_ 11/12/2020
Mig .re of Hauler Date
Signature of Receiving Facility Date
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