HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 39 PADDOCK LANE 1/11/2022 REGEWa
Commonwealth of Massachusetts N 112022
City/Town of North Andover �A
System Pumping Record wNOFNoVkPAR ME TEa
Form 4 SOHEA�THpE
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 39 Paddock Lane
key to move your Address
cursor-do not North Andover MA 01845-6311
use the return - --- _ -- - - -- - - --
key.
City/Town State Zip Code
m
2. System Owner:
Brian Mark
Name
iam
Address(if different from location)
City/Town State Zip Code
617-777-0453
Telephone Number
B. Pumping Record
12/10/2021 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 or V85257
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
12/10/2021
eSiure of Hauler Date
Signature of Receiving Facility Date
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