HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 72 WINDSOR LANE 5/9/2023 Commonwealth of Massachusetts Eo
City/Town of North Andover a
System Pumping Record
��y41 Form 4
N F;S
DEP has provided this form for use by local Boards of Health. Other forms m? F6 ,QI Fthe
information must be substantially the same as that provided here. Before using 41Fs1`?Srm, 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 72 Windsor Lane -
key to move your Address
cursor-do not North Andover MA 01845-5636
use the return key. City/Town State Zip Code
m
2. System Owner:
�(,�� /�j♦I���� Adam Davies
I� Name - - - -- -
nan
Address(if different from location)
City/Town State Zip Code
978-404-9079
Telephone Number
B. Pumping Record
1. Date of Pumping 4/10/2023 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
4/10/2023 _
eSi .e of Hauler Date
Signature of Receiving Facility Date
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