HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 101 BRIDGES LANE 2/7/2022 RECEIVEt
°0 Commonwealth of Massachusetts
City/Town of North Andover FEB p 2022
System Pumping Record TOWN OF NORT11AN110VEI'
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 101 Bridges Lane
key to move your Address
cursor-do not North Andover MA 01845-2220
use the return
key. City/Town State Zip Code
dlt� 2. System Owner:
V m�
Stephen Cammarata
Name
Address(if different from location)
City/Town State Zip Code
617-913-1726
Telephone Number
B. Pumping Record
1. Date of Pumping 01/4/2022 1500
Date _ -- — 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -
4. Effluent Tee Filter present? N Yes ❑ No If yes,was it cleaned? N 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
01/4/2022
S-1917fure of Hauler Date
Signature of Receiving Facility Date
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