HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 168 GRAY STREET 8/14/2025 Commonwealth of Massachusetts Town Of North AndoVer
(i,� City/Town of North Andover
System Pumping Record SEP 10 2025
Form 4
Hea
DEP has provided this form for use by local Boards of Health. Other foruprriI;* r�qqv A.
information must be substantially the same as that provided here. Before using 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 15.3�51.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 168 Gray Street
------ ..........
key to move your Address
cursor-do not North Andover MA 01845-6302
use the return
key. City/Town State Zip Code
VQ 2. System Owner:
Erik Collart
Name
. ............... — — -- ----------------------............................................................... .....................................
Address(if different from location)
city/Town State Zip Code
978-984-5520
Telephone Number-
..............
B. Pumping Record
-1500
1. Date of Pumping mate.I 1 2. Quantity Pumped: 6 -allons-
1 Type of system: M Cesspool(s) Septic Tank n Tight Tank El Grease Trap
ElOther(describe): ------------------------------- -,",--- ---- -..............................................................................................
4. Effluent Tee Filter present? X Yes ❑ No If yes, was it cleaned? X Yes n No
5. Condition of System:
Good, system operating properly
----------------- ---------------- ------------
6. System Pumped By:
Jason Elliott S71437 or V85257
-Na-me ------ --Vehicle License---Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
8/14/2025
Si, ure of Hauler Date
Signature of ReceivingFacility--------- -Date - ------
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