HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 56 SUGARCANE LANE 8/14/2023 Commonwealth of Massachusetts
NEP�'�N
City/Town of North Andover 141023
System Pumping Record p,�G
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 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 56 Sugarcane Lane
key to move your Address
cursor-do not North Andover MA 01845-3248
use the return - -- — - - -
City/Town State Zip Code
key.
�1 2. System Owner:
m
Lisa Staff
Name
gem
Address(if different from location)
City/Town State Zip Code
978-686-2664 617-240-8180
Telephone Number
B. Pumping Record
1. Date of Pumping 7/25/2023 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
7/25/2023
eS,gure of Hauler Date
Signature of Receiving Facility Date
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