HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 171 SUMMER STREET 7/1/2025 L\ Commonwealth of Massachusetts )f1V~_ �
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Form 4
DEP has provided this form for use by local Boards of Health. Other nml Ma
informadonmust bomube1an1iaUy the same aa that provided here. Before using thihf�`��6 thyour
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health ur other approving authority within 14 days from the pumping date in
accordance with 31OCyWR15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 171 Summer Street
keym move your Address
cursor-do not
North Andover MA 01845
use the return
ka» City/Town State Zip Code
2. System Owner:
�—� Megan Sweeney
Name
State Zip Code
078-618-1508603-533-6472
Telephone Number
B. Pumping Record
1. Date ofPumping 7/1/2025 2� DuantityPumpad� 1200
3. Type ofsystem: Fl Cesspool(s) Septic Tank F1 Tight Tank [l Grease Trap
L] Other(describe):
4. Effluent Tee Filter present? Yes No U yes,was itcleaned? Yee E No
5. Condition of System:
Good, system operatingproperly
6. System Pumped By:
Jason Elliott S71437 orV85257
Vehicle License Number
|veahmr and Elliott Services LLC-DQAJason
El liott Pu m pin
7. Location where contents were disposed:
GLSD
7/1/2025
M 11111111111.111 111---------- - .
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