HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 268 REA STREET 7/18/2022 RECEIVED
Commonwealth of Massachusetts 3UL 18 2022
City/Town of North Andover OF t�ORTH
System Pumping Record TO HEALTH DEPARTMENT
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 268 Rea Street
key to move your Address
cursor-do not North Andover MA 01845-4813
use the return -City/Town State Zip Code-- -- — - --—
key.
VQ 2. System Owner:
James Lynch
Name - - -- - - - - -..-- - ---
Address(if different from location)
City/Town State Zip Code
508-523-4081
Telephone Number
B. Pumping Record
6/8/2022 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
Wester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
_ 6/8/2022
Sig ure of Hauler Date
Signature of Receiving Facility Date
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