HomeMy WebLinkAboutSeptic Tank - Miscellaneous - 466 SALEM STREET 3/5/2024 Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
v
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 musl,be=goi�Titted to
the local Board of Health or other approving authority within 14 days from the p0mo,lt7g d'at in
accordance with 310 CMR 15.351.
A. Facility Information 0
Important:When
filling out forms 1. System Location: tt�}E:�t
on the computer, '° '
use only the tab 466 Salem Street
key to move your Address
cursor-do not North Andover MA 01845-3110
use the return City/Town State Zip Code
key.
�1 2. System Owner:
V m�
Mark McDevitt
Name
nom
Address(if different from location)
City/Town State Zip Code
781-366-5738
Telephone Number
B. Pumping Record
1. Date of Pumping 02/21/2024 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? X Yes ❑ No If yes, was it cleaned? X 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
-60� 02/21/2024
Sig ere of Hauler Date
Signature of Receiving Facility Date
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