HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 54 STERLING LANE 6/9/2022 Commonwealth of Massachusetts ae0E1VEo
(A City/Town of North Andover
System Pumping Record SUN p g2022
Form 4 aTH AN�OTER
TowN OTH OEPAaTMEN
DEP has provided this form for use by local Boards of Health. Other forms mayhliW'sed, 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 54 Sterling Lane
---_----------
key to to move your Address
cursor-do not North Andover MA 01845
use the return
City/Town State Zip Code
key.
m
2. System Owner:
Jonathan Mandell
Name
lain
Address(if different from location)
City/Town State Zip Code
781-698-7379
Telephone Number
B. Pumping Record
1. Date of Pumping 5/23/2022 2. Quantity Pumped: 1500
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:
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
M- 5/23/2022
Sig ure of Hauler Date
Signature of Receiving Facility Date
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