HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 255 OLD CART WAY 8/14/2025 Commonwealth
������������\�����/u ' ^//
��'fo7T �� Y�North Andover
�� ����� ��
�� y/ / `^/ /� / �/ /
System Pumping Record
Form 4
DEP has provided this form for use by|000| Boards of Health. 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 31OCIWR15.351.
A, Facility Information
Important:When
filling out mnna 1. System Location:
on the computer,
use only the tab 255 Old Cart
key m move your Address
cursor do not
North Andover [NA 01845-6346
use the�turn
uoy� ~`'''~'`'' State Zip Code
2. System Owner:
~---� Jennifer Thorn
Name
617-828-1126
B. Pump'ng Record
1. Date ofPumping 8/14�!O25 2� 0uantityPumpmd� 1500
Gallons-
3. Type ofsystem: Fl Cesspool(s) Z Septic Tank Fl Tight Tank n Grease Trap
E1 Other(describe):
4. Effluent Tee Filter present? Yes Z No |f yes, was itcleaned? Yes Z No
5. Condition ofSystem:
Good system tiproperly
8. System Pumped By:
Jason Elliott S71437 orV85267
-Vehicle License Number
|vaobar and Elliott Services LLC-]BAJason
Elliott P m i
7. Location where contents were disposed:
GLSD
8/14/2025
-%Si�— re of Hauler D a t e
ignature of Receiving Facility Date
mmnn4.do*^03m6 System Pumping Record^Page 1ms