HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 115 JOHNNY CAKE STREET 7/19/2023 Commonwealth of Massachusetts N�P�
City/Town of North Andover ,�`19 tipti3
System Pumping Record
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 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, 115 Johnny Cake Street —.
use only the tab
key to move your Address 01845
cursor-do not North Andover MA Zip Code
use the return Cityrrown State
key.
2. System Owner:
vlam=A
Laura Sincerbeaux
Name
row
Address(if different from location)
State Zip Code
City/Town 910-988-9044
Telephone Number
B. Pumping Record
6/19/2023 1500
D
1. Date of Pumping ate 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
Vehicle License Number
Name
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD — --
6/19/2023
esiur:eof:H:a�uu�1er -_
Date
Signature of Receiving Facility Date
System Pumping Record•Page 1 of 5
t5form4.doc•03/06