HomeMy WebLinkAboutSeptic Pumping Slip - 659 Forest St - Septic Pumping Slip - 659 FOREST STREET 9/11/2024 Commonwealth of Massachusetts
City/Town of North Andover
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
tilling out forms 1. System Location:
on the computer,
use only the tab 659 Forrest Street
key to move your Address
cursor-do not North Andover MA 01864
use the return CilyfTown State Zip Code
key.
2. System Owner:
res
Zhylinski
Name
IPdAn ',
Address(it different from location)
City/Town State Zip Code
857-928-9394
ielophono Number ',
B. Pumping Record
1. Date of Pumping 9/11/2024 2. Quantity Pumped: 1000}
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:
Fluid level high in tank
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
9/11/2024
Sl ure of Hauler Date
_...... m _._.... ..
Signature of Receiving Facility pate
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