HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 56 SUGARCANE LANE 8/12/2025 (3) l
Commonwealth of Massachusetts Town Ofordover
(, City/Town of North Andover
System Pumping Record SEP 10 2025
Form 4
llec')Ith
DEP has provided this form for use by local Boards of Health. Other forms m
information must be substantially the same as that provided here. Before usin gthis this form, 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 310 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 56 Sugarcane Lane
- ---- --------------------------------- ....................................... ................................................
key to move your Address
cursor-do not North Andover MA 01845-3248
use the return C,i"t,y-I-T-o"w-n State
t-a I t 11 e -Zip Code -
key,
VQ 2. System Owner:
Lisa Staff
Name
............................. --- - -------- ........................ ............-
Address-(if-different from location)
---- ------------------------ t- --- Zi—p n State -c ode-
978-686-2664 617-240-8180
Telephone N u m b er
B. Pumping Record
1. Date of Pumping 8/12/2025 2. Quantity Pumped: 1500
[late 6aflon-s-
3. Type of system: El Cesspool(s) Septic Tank ❑ Tight Tank F1 Grease Trap
Ej Other(describe): --------------- ............
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes No
5. Condition of System:
Good, system operating properly
......................................................
6. System Pumped By:
Jason Elliott S71437 or V85257
....................
Name - Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
..........................
7, Location where contents were disposed:
GLSD
8/12/2025
-es Hauler Date
Signature of Receiving Facility 'Date'
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