HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2001 SALEM STREET 9/18/2025 Town of North Andover
L\ Commonwealth of Massachusetts
4- mmw. 'City/Town of North Andover OCT 6 2025
System Pumping Record
Form 4 Health Department
DEP has provided this form for use by local 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 310 CIVIR 15.351.
-------------- -----------............
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 2001 Salem Street
key to move your Address
cursor-do not North Andover MA 01845
use the return
key. City/Town State Zip Code
VQ 2. System Owner:
Erin Blanchard
........ .....
Name .
raedn
............. ......................................
Address' '-(if different-- - from
. ...........
Cityaown- State Zip.-.Code
-... ............................. ...........
802-318-5715 617-921-2682
Telephone Number - --- - -
B. Pumping Record
1. Date of Pumping .9/18/2025 2. Quantity Pumped: 1500
Date- - Gallons
3. Type of system: El Cesspool(s) Septic Tank R Tight Tank ❑ Grease Trap
R Other(describe): -------------------------------- ...... -----------------------------
4. Effluent Tee Filter present? X Yes R No If yes, was it cleaned? X 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
9/18/2025
-esi —,-"re,of-Hauler Date
Signature of Receiving Facility Date
t5form4.doc-03/06 System Pumping Record-Page 1 of 11