HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 115 JOHNNY CAKE STREET 7/1/2025 ' '=px/ ��
y�[)UlD0��DVV���H� n� K�������(�����ft � �' /V0�� ���� Commonwealth .~. Massachusetts~,.~~ `'rV/[��b�r
��' rr� North �n,� -�,�v
��|T\/ | [�\8/D `�/ /v��. u : Andover
~ . AUG
���ste�� ������8�� R������ "o
� Pumping ��
Form 4 H_
-'"
DEP has provided this form for use by local Boards of Health. Other
information must be substantially the same as that provided here. Before using this form. your
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 doba in
accordance with 318CIWR15.351.
A, Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 115 Johnny Cake Street
key to move your Address
cursor do not
North Andover [NA 01845
use�oreturn
key. ~'^''~~^ ^a Zi
p'C""=
4:12. SystemOwner:
— Laura Simcerbeaux
ress(if different from location)
910-888-9044207-458-2726
lepho-ne Number
B. Pumping Record
�1�O25 1500
1. Date ofPumping 3. Quantity Pumped: Gallons
3. Type ofsystem: [] Cesspool(s) Septic Tank Fl Tight Tank R Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? Yes No |f yes, was |icleaned? Yes No
5. Condition of System:
Good system operating properly
6. System Pumped By:
Jason Elliott S71437orV85257
|waaterand Elliott Services LLC-DBAJoaon
Elliott Pumping
7. Location where contents were disposed:
GL8D