HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 229 GRAY STREET 6/26/2023 n � \
Commonwealth of Massachusetts
City/Town of North Andover C
System Pumping Record
wL
Form 4
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 submmi ted to
the local Board of Health or other approving authority within 14 days from the pumping c�a iq\�N
accordance with 310 CMR 15.351.
A. Facility Information
Important:When j11N a�j 2023
filling out forms 1. System Location: JU
on the computer,
use only the tab 229 Gray Street
key to move your Address
cursor-do not North Andover MA 01845
use the return --- —
key.
City/Town State Zip Code
2. System Owner:
Jason DiPrimo
Name —
Warn
Address(if different from location)
City/Town State Zip Code
978-902-3027
Telephone Number
B. Pumping Record
1. Date of Pumping 5/1/2023 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
5/1/2023
Sig ure of Hauler Date
Signature of Receiving Facility Date
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