HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 131 PHEASANT BROOK ROAD 11/8/2022 (3) Commonwealth of Massachusetts ����� �
(.A City/Town of North Andover
System Pumping Record
Form 4 00M�
DEP has provided this form for use by local Boards of Health. Other forms may b�f ,fs ,�e
information must be substantially the same as that provided here. Before using this 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 131 Pheasant Brook Rd.
key to move your Address
cursor-do not North Andover MA 01845-3372
use the return City/Town State Zip Code
key.
2. System Owner:
Danielle Perry
Name
nem
Address(if different from location)
City/Town State Zip Code
978-794-1727 978-478-7700
Telephone Number
B. Pumping Record
10/11/2022 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
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
10/11/2022
rSi$ure of Hauler Date
Signature of Receiving Facility Date
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