HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 113 BRIDGES LANE 4/19/2022 OFCENED
Commonwealth of Massachusetts
City/Town of North Andover APR 19 2022
System Pumping Record ANDOVE
?OWN NORTH
Form 4 HE'TH 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 113 Bridges Lane
key to move your Address
cursor-do not North Andover MA 01845
use the return key. City/Town State Zip Code
01—�
1/� 2. System Owner:
Docarmo
Name
iatm
Address(if different from location)
City/Town State Zip Code
617-337-7607
Telephone Number
B. Pumping Record
3/29/2022 1500 Tank+
1. Date of Pumping Date 2. Quantity Pumped: Chamber
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
3/29/2022
Sig ure of Hauler Date
Signature of Receiving Facility Date
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