HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 67 ROCKY BROOK ROAD 10/17/2022 Commonwealth of Massachusetts
City/Town of North Andover tiCV oo��
I System Pumping Record
Form 4
L DEP has provided this form for use by local Boards of Health. Other forms may be used,
information must be substantially the same as that provided here. Before using this fornck with your
local Board of Health to determine the form they use.The System Pumping Record mitt 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, 67 Rock Brook Road
use only the tab y
key to move your Address
cursor-do not North Andover MA 01845
use the return State Zip Code
City/Town
key.
2. System Owner:
m
Jay Huapaya
Name
nem
Address(if different from location)
CityFrown State Zip Code
978-697-1842
Telephone Number
B. Pumping Record
9/29/2022 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
9/29/2022
Sig ure of Hauler Date
Signature of Receiving Facility Date
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