HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 JERAD PLACE 2/7/2024 Commonwealth of Massachusetts Town of North Andover
City/Town of North Andover FEB 0 7 2024
System Pumping Record
Form 4
H el 11D,i,`` rtment
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 10 Jeran Place
key to move your Address
cursor-do not North Andover MA 0184_5 _
use the return key. City/Town State Zip Code
2. System Owner:
m
Levine
. Name
nem
Address(if different from location)
City/Town State Zip Code
978-615-3099
Telephone Number
B. Pumping Record
1. Date of Pumping 01/24/2024 1500
Date 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:
Heavy grease
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
01/24/2024
Sig ure of Hauler Date
Signature of Receiving Facility Date
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