HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 544 JOHNSON STREET 7/30/2025 Commonwealth nfMassachusetts
IV
City/Town of North Andover
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Form 4 ��r '
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DEP has provided this form for use by local Boards ofHealth. Dth
' information must baoubobandaUy the same as that provided here. your
local Board of Health to determine the form they use. The System Pumping � submitted to
the local Board of Health or other approving muthnhtyvvithin14 days�omthapumpin�
accordance with 31OCMR15.351. ^v
A, Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 544JohnaonS�e�\
key m move your Address
cursor-do not
North MAO1845
use the�mm
City/Town State �powue
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2. System Owner:
^---~ Michael Donnelly
Name
c/�omwn State Zip Code
508-932-3254
Te|*phunemumuer
B. Pumping Record
7/3O/2O25 1500
1. Date ofPumping 2� Quantity
3. Type ofsystem: [l Cesspool(s) Septic Tank Fl Tight Tank [l Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? Yes No |f yes, was itcleaned? Yea E No
5. Condition of System:
Good system o properly
S. System Pumped By:
Jason Elliott S71437 or V85257
mamo Vehicle License Number
|vester and Elliott Services LLC-DBAJason
B|i oft P u m pin
7. Location where contents were disposed:
GLSD
7/30/2025
es 'reof-lda-uler- ------
signatureor Receiving Facility Date