HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 DUNCAN DRIVE 12/9/2020 RECEIVED
Commonwealth of Massachusetts DEC 0 0 2020
W City/Town of North Andover TOWN OF NORTH ANDOVER
System Pumping Record HEALTH DEPARTMENT
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 50 Duncan Drive
key to move your Address
cursor-do not North Andover _ MA _ 01845
use the return
key. City/Town State Zip Code
Q2. System Owner:
Seon Jeong, Qdexcyma Technologies LLC
Name - -NAM --
Address(if different from location)
City/Town State Zip Code
978-810-5146
Telephone Number
B. Pumping Record
11/28/2020 1500
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
11/28/2020
Sig ure of Hauler Date
Signature of Receiving Facility Date
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