HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 56 SUGARCANE LANE 8/12/2025 Commonwealth nfMassachusetts
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Record
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Form 4
DEP has provided this form for use by local Boards cfHealth. Other forms may be 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 31OC[WR1S.351.
A. Facility Information
Important:When
filling out mmm 1. System Location:
on the computer,
use only the tab 56 Sugarcane Lane
key to move your »dumoo
cursor-do not
North Andover MA 01845-3248
use the return
key. ~'`'''~—' State Zip Code
2. System Owner:
�---` Lisa Staff
ress(if different from location)
978-086-2684817-240-8180
Telephone Number
B. Pumping Record
8/12/2025 1500
1. Date ofPumping 2. Quantity Pumped:
3. Type ofsystem: Ej Cesspool(s) 0 Septic Tank [l Tight Tank [l Grease Trap
LJ Other(describe):
4. Effluent Tee Filter present? Yee No |f yes, was itcleaned? Yes No
S. Condition of System:
Good, i ,properly
0. System Pumped By:
Jason Elliott S71437orV85257
|veeter and Elliott Services LLC-OBAJason
Elliott Pumping
7. Location where contents were disposed:
6L8D