Loading...
HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1809 SALEM STREET 4/1/2025 Commonwealth of Massachusetts City/Town of North Andover System Pumping Record Form 4 -u- 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 1809 Salem Street key to move your Address cursor-do not North Andover MA 01845 use the return key. City/Town State Zip Code 2. System Owner: r� Susan Severin Name return Address(if different from location) City/Town State Zip Code 978-844-3490 Telephone Number B. Pumping Record 1. Date of Pumping 4/1/2025 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? 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 4/1/2025 Si ure of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 10 Commonwealth of Massachusetts City/Town of North Andover System Pumping Record Form 4 -u- 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 1454 Salem Street key to move your Address cursor-do not North Andover MA 01845 use the return key. City/Town State Zip Code 2. System Owner: r� Brett Belcastro Name return Address(if different from location) City/Town State Zip Code 617-778-8747 Telephone Number B. Pumping Record 1. Date of Pumping 4/14/2025 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 4/14/2025 Si ure of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 10 Commonwealth of Massachusetts City/Town of North Andover System Pumping Record Form 4 -u- 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 80 Bradford Street key to move your Address cursor-do not North Andover MA 01845 use the return key. City/Town State Zip Code 2. System Owner: r� Dolores Boettcher Name return Address(if different from location) City/Town State Zip Code 978-522-4115 Telephone Number B. Pumping Record 1. Date of Pumping 4/14/2025 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? Yes ® No If yes, was it cleaned? Yes ® No 5. Condition of System: Back flushed 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 4/14/2025 Si ure of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 10 Commonwealth of Massachusetts City/Town of North Andover System Pumping Record Form 4 -u- 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 25 Windsor Lane key to move your Address cursor-do not North Andover MA 01845 use the return key. City/Town State Zip Code 2. System Owner: r� Tod Labrie Name return Address(if different from location) City/Town State Zip Code 617-821-1400 Telephone Number B. Pumping Record 1. Date of Pumping 4/14/2025 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? 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 4/14/2025 Si ure of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 10 Commonwealth of Massachusetts City/Town of North Andover System Pumping Record Form 4 -u- 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 Turnpike key to move your Address cursor-do not North Andover MA 01845 use the return key. City/Town State Zip Code 2. System Owner: r� C/O Ben Osgood Olde Salem Village Name return Address(if different from location) City/Town State Zip Code 508-328-4630 Telephone Number B. Pumping Record 1. Date of Pumping 4/17/2025 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? Yes ® No If yes, was it cleaned? Yes ® No 5. Condition of System: Pump chamber 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 4/17/2025 Si ure of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 10 Commonwealth of Massachusetts City/Town of North Andover System Pumping Record Form 4 -u- 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 754 Boxford Street key to move your Address cursor-do not North Andover MA 01845 use the return key. City/Town State Zip Code 2. System Owner: r� Amanda Geiger Name return Address(if different from location) City/Town State Zip Code 978-317-4199 Telephone Number B. Pumping Record 1. Date of Pumping 4/23/2025 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 4/23/2025 Si ure of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 10 Commonwealth of Massachusetts City/Town of North Andover System Pumping Record Form 4 -u- 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 59 Rocky Brooke Road key to move your Address cursor-do not North Andover MA 01845 use the return key. City/Town State Zip Code 2. System Owner: r� Doucette Name return Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 4/25/2025 2. Quantity Pumped: 15000 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: 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 4/25/2025 Si ure of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 10 Commonwealth of Massachusetts City/Town of North Andover System Pumping Record Form 4 -u- 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 36 Windsor Lane key to move your Address cursor-do not North Andover MA 01845 use the return key. City/Town State Zip Code 2. System Owner: r� Thomas Royce Name return Address(if different from location) City/Town State Zip Code 781-413-7092 Telephone Number B. Pumping Record 1. Date of Pumping 4/29/2025 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? 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 4/29/2025 Si ure of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 10 Commonwealth of Massachusetts City/Town of North Andover System Pumping Record Form 4 -u- 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 163 Olympic Lane key to move your Address cursor-do not North Andover MA 01845 use the return key. City/Town State Zip Code Q2. System Owner: Kathryn Secondo Name rerun Address(if different from location) City/Town State Zip Code 617-694-7463 Telephone Number B. Pumping Record 1. Date of Pumping 4/29/2025 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 4/29/2025 Si ure of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 10 Commonwealth of Massachusetts City/Town of North Andover System Pumping Record Form 4 -u- 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 701 Forest Street key to move your Address cursor-do not North Andover MA 01845 use the return key. City/Town State Zip Code 2. System Owner: r� Carol Martin Name return Address(if different from location) City/Town State Zip Code 978-360-3689 Telephone Number B. Pumping Record 1. Date of Pumping 4/4/2025 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? 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 4/4/2025 Si ure of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 2 of 10