HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 66 SAVILLE STREET 12/28/2021 Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
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 66 Saville Street
key to move your Address
cursor-do not North Andover MA_ 01845-6159
use the return City/Town State Zip Code
key.
2. System Owner:
VOID"
David Smith
Name -- -------
nasn
Address(if different from location)
a wy/T—ow n State Zip Code
978-258-7799 978-397-2338
Telephone Number
B. Pumping Record
1. Date of Pumping 11/11/2021 2 Quantity Pumped: 1000
Date 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:
Pump chamber only Good, system operating properly
6. System Pumped By:
Jason Elliott S7143_7 or V85257
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
11/11/2021
eS.e of Hau_ler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 11