HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 450 FOSTER STREET 10/17/2022 Commonwealth of Massachusetts
City/Town of North Andover ��
System Pumping Record ����
Form 4 Off'`~ O�qQ-
v �O
DEP has provided this form for use by local Boards of Health. Other forms may be used, b(�JeI6
information must be substantially the same as that provided here. Before using this forrT, k with your
local Board of Health to determine the form they use.The System Pumping Record mX9{s0 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 450 Foster Street
key to move your Address
cursor-do not North Andover MA 01845
use the return City/Town State Zip Code
key.
na
2. System Owner:
Thomas Lang
Name
sera
Address(if different from location)
City/Town State Zip Code
978-685-8379
Telephone Number
B. Pumping Record
1. Date of Pumping 9/22/2022 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
9/22/2022
Si ure of Hauler Date
Signature of Receiving Facility Date
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