HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 121 RALEIGH TAVERN LANE 5/9/2023 aEce%ve\)
Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record ts0�V10 P,9
Form 4 101 MiN INA
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, 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 121 Raleigh Tavern Lane
key to move your Address
cursor-do not North Andover. MA 01845-5627
use the return key. City/Town State Zip Code
2. System Owner:
m
David Slagle Jr.
Name —
rwm
Address(if different from location)
City/Town State Zip Code
978-273-4084
Telephone Number
B. Pumping Record
1. Date of Pumping 4/10/2023 pate - 2. Quantity Pumped: 1500
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
Sig ure of Hauler Date
Signature of Receiving Facility Date
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