HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 325 BERRY STREET 3/24/2025 �^�. '� ����
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System Pumping Record Health Department
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 dote in
accordance with 31OCK8R1S.3S1,
A, Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 325 Berry Street
key m move your xunremo
cursor do not
North Andover MA 01845
use the return
key. ~^,'.~.. ~..`^ Zip Code
2. System Owner:
^---~ Sean Dunn
Name
978-979-3085
Telephone Number
B. Pumping Record
1. Oahs of Pumping 3/24/2025 2� (Quantity Pumped: 1500
Gallons
3. Type ofsystem: F Cesspool(s) E Septic Tank [l Tight Tank El Grease Trap
F] Other(describe):
4. Effluent Tee Filter present? Yen No |f yes, was itcleaned? Yes Z No
5. Condition ofSystem:
Good, systemoperating properly
6. System Pumped By:
JesonB|iott G71437orV85257
Name Vehicle License Number
|vester and Elliott Services LLC'DBAJason
Elliott Pumping
7. Location where contents were disposed:
8LGD
3/24/2025
D, u,e-of Hauler E�a_te __
Signature of Receiving Facility Date
t5fonn4.uoc^03m6 System Pumping Record~Page 1o,r