HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 255 OLD CART WAY 8/14/2025 Commonwealth of Massachusetts Town of doVer
�p City/Town of North Andover SEE 10 2025
System Pumping Record
Form 4 Hecilth L)epc.1rtrn
DEP has provided this form for use by local Boards of Health. Other forms may be us 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 310 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 255 Old Cart Way
......................................... ----------
key to move your Address
cursor-do not North Andover MA 01845-6346
use the return
key. City/Town State Zip Code
VQ 2. System Owner:
Jennifer Thorn
------------------------ - ---------------------------------------------
Name
Address-(if different from m location) .............
City/Town State Zip Code
617-828-1126
Telephone Number
B. Pumping Record
8/14/2025 1500
.... ...—----- 2. Quantity Pumped: 1-Gallons
-all.....o...
1. Date of Pumping n-s..--
Date
3. Type of system: ❑ Cesspool(s) Septic Tank n Tight Tank F-1 Grease Trap
ElOther(describe): 11 - --l-11-11...............1-11111............ ----------------------------------------------------- — --- --- ..................................................................
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
8/14/2025
-eSi — u,e of Hauler Date
I - ..............
Signature of Receiving Facility Date
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