HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 241 FARNUM STREET 9/13/2021 Commonwealth of Massachusetts RECEIVED
(� City/Town of North Andover SEP 1 3 c021
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
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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 241 Farnum Street
key to move your Address
cursor-do not North Andover _ MA _ _ 01945-5607
use the return key. City/Town State Zip Code
Q2. System Owner:
Steven Gardell
Name
nem
Address(if different from location)
City/Town State Zip Code
978-807-3895
Telephone Number
B. Pumping Record
8/2/2021 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:
Heavy W/solids
6. System Pumped By:
Jason Elliott S71437 or V85257
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
8/2/2021
%Si .re of Hauler Date
Signature of Receiving Facility Date
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