HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 54 STERLING LANE 7/19/2023 Commonwealth of Massachusetts
City/Town of North Andover &�9tioti
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
filling out forms 1. System Location:
on the computer,
use only the tab 54 Sterling Lane -
key to move your Address 01845
cursor-do not North Andover MA
use the return City/Town State Zip Code
key.
2. System Owner:
m
Tara Haas
Name
noun
Address(if different from location)
City/Town
State Zip Code
978-394-3614
Telephone Number
B. Pumping Record
6/8/2023 1500
1. Date of Pumping 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:
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
6/8/2023
esigure Lof Hauler Date
Signature of Receiving Facility Date
System Pumping Record•Page 1 of 5
t5form4.doc•03/06