HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 WINDKIST FARM ROAD 3/31/2025 lown of NorthAndover
` Commonwealth of Massachusetts APR 10
202
Health=�: City/Town of North Andover
System Pumping Record
1 Form 4 rtmen
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 45 Windkist Farm Road
------ ..........._...- --— ..
key to move your Address
cursor-do not North Andove..................... _- ------ _............. ............._.......... .�. —-----.._.__... _._..._....._�.._-------..__...............---_............_...... -
key.
City/Town State Zip Code
2. System Owner:
Stephen Costa -- - —_._.-.___
Name
Stan
— _-._._._-_--_-_ ----.. ---.--......__-_......_....
_..._..._._.___
Addre._ss(if different from location)
.................__... -. _._...
City/Yawn State Zip Code
781-484-7203
Telephone Number
B. Pumping Record
3/31/2025 1500
1. Date of Pumping -- 2. Quantity Pumped: ----------..___ _
Datteo Lallans
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
3/31/2025
e--d . _.._._ul—er -- ----e of Hauler Date
Signature of Receiving Facility Date
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