HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 703 MIDDLETON STREET 10/17/2022 Commonwealth of Massachusetts �100
City/Town of North Andover ��� �,�otiti�ooAP
IS System Pumping Record
Form 4 �QP
O �O
DEP has provided this form for use by local Boards of Health. Other forms may be useq,,*joe
information must be substantially the same as that provided here. Before using this foO,.Vreck 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 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 703 Middleton Road
key to move your Address
cursor-do not North Andover MA 01845-6341
use the return City/Town State Zip Code
key.
2. System Owner:
Glowacki
Name
ram
Address(if different from location)
City/Town State Zip Code
781-215-1436
Telephone Number
B. Pumping Record
1. Date of Pumping 9/22/2022 2. QuantityPumped: 1500
p g p 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
9/22/2022
Si ure of Hauler Date
Signature of Receiving Facility Date
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