HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 21 DEER MEADOW ROAD 10/7/2021 Commonwealth of Massachusetts RECEIVED
City/Town of North Andover ` '
System Pumping Record TOWN OF NORTH ANDOVER
L` Form 4 HEALTH DEPARTMENT
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 21 Deer Meadow Road -
key to move your Address
cursor-do not North Andover MA 01845-1440
use the return key. City/Town State Zip Code
m
2. System Owner:
Jeffrey Faucon
Name
Address(if different from location)
City/Town State Zip Code
978-533-9247
Telephone Number
B. Pumping Record
9/29/2021 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:
Good, system operating properly
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
9/29/2021
Si ure of Hauler Date
Signature of Receiving Facility Date
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