HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 60 RALEIGH TAVERN LANE 7/15/2025 IZ\ Commonwealth of Massachusetts 7bwn C"f N011h
�p City/Town of North Andover
System Pumping Record
Form 4 2 ,5
DEP has provided this form for use by local Boards of Health. Other forM9' 11ir sed, but the
information must be substantially the same as that provided here. Before using Majeck with your
local Board of Health to determine the form they use. The System Pumping Record must P! l4ttted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 60 Raleigh Tavern Road ------
key to move your Address
cursor-do not North Andover MA 01845
use the return --------- ------------------------------ .................................
key. City/Town State Zip Code
VQ 2. System Owner:
Robert Rogers
Nam-e--- - ------- -- - ------ - - ------ -- ------------- ----- -------- --- - --
Address(if different from location)
-------------------------------- ----------------------------- ... -------- ----------
City/Town State Zip Code
978-815-9284
Telephone Number
B. Pumping Record
1. Date of Pumping 7/15/2025 2. Quantity Pumped: 1500
Date Gallons
3. Type of system: FT Cesspool(s) Septic Tank ❑ Tight Tank R Grease Trap
ROther(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
NameVehicle License..Number
.. ., .......... ...............
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSID
7/15/2025
Si ure of Hauler Date -----
Signature of Receiving Facility Date
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