HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 148 CROSSBOW LANE 12/28/2021 Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
�y 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 148 Crossbow Lane
key to move your Address
cursor-do not North Andover MA 01845-3038 _
use the return City/Town State Zip Code
key.
2. System Owner:
Andrew Cournoyer
Name
Address(if different from location)
City/Town State Zip Code
339-221-4058
Telephone Number
B. Pumping Record
11/17/2021 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
R67 11/17/2021
Si ure of Hauler Date
Signature of Receiving Facility Date
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