HomeMy WebLinkAboutSeptic Pumping Slip - 35 Evergreen - 10/24/24 - Septic Pumping Slip - 35 EVERGREEN DRIVE 10/24/2024 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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 35 Evergreen Drive
- ---------- ......
key to move your Address
cursor-do not North Andover MA 01845
use the return --1----'---.............
key. City/Town State Zip Code
2. System Owner:
Sherri Dinush
Name
......-------
Address(if different from location)
City/Town- -state Zip Code
978-376-6777 781-572-4782
Telephone- ,-—Number
11-11 1 11 I I
B. Pumping Record
10/24/2024 1500
1. Date of Pumping I t I e 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank n Tight Tank El Grease Trap
nOther(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
11111111 1 1 1111 1 - S71437 or V852. 57
.. ..
Name ...................................
Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
.......................
7. Location where contents were disposed:
GLSD
10/24/2024
............ ---
Si ure f Hauler Date
............ -----------------------------
Signature of Receiving Facility Date
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