HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 734 FOSTER STREET 7/30/2025 Commonwealth of Massachusetts Town of North Andover
City/Town of North Andover
System Pumping Record AUG 11 2025
m Form 4
k" " $P,Y % q al tent
DEP has provided this form for use by local Boards of Health. Of er"forms may Ede 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 734 Foster Street
key to move your Address _ _
cursor-do not North Andover MA a1845-1434
use the return - --- _
key. City/Town State Zip Code
VQ 2. System Owner:
James Clawson
Name
Address(if different from location)
-— -- __........
City/Town State Zip Code
978-682-5611 978-314-885a
Telephone Number.. _
B. Pumping Record__ _
7/3a/2a25 15aa
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
7/30/202 5
_ e of Hauler' Date - ---------
--_..................._..._._ _ _ _.._._............................_....____........ ....._..... _..__...___...__......_____.._.__._._............._ —---------------------_.----__..___...__......_._._.......
Signature of Receiving Facility Date
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