HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 45 LACY STREET 8/1/2025 T^xm� rf North mVV|| m m | A |UUver
Commonwealth of Massachusetts SEP 10 2025
��' of North Andover
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Systemd.
Pumping Record Hea!'h Department
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must ba substantially the same as that provided here. Before using this form, check with your
local Board Vf 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 31OCK4R15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 45 Lacy Street
key m move your aoue*o
uurx",-do not
North Andover MA 01845
use the n$um
x�y� ~^r'~'`'' State Zip Code
2. System Owner:
~---� Michael Hale
K11111
ame
'Addre-ss-(if-different-from location)
ity/Town State Zip Code
847-924-5379
.-feie ph one Number
B. Pumping Record
8V1/2O25 15OO
1. Date ofPumping 2� (�uandtyPumped�
3. Type ofsystem: Cesspool(s) Z Septic Tank Fl Tight Tank M Grease Trap
LJ Other(describe):
4. Effluent Tee Filter present? Yea No K yes, was itcleaned? Yee No
5. Condition ofSystem:
Good t� dproperly
S. System Pumped By:
Jason Elliott S71437 or V85257
-Name Vehicle License Number
|veator and Elliott Services LLC-DBAJason
B|i oft Pumping
7. Location where contents were disposed:
GLSD