HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 155 LACONIA CIRCLE 9/22/2025 Commonwealth of Massachusetts Town of NOfth AndWer
City/Town of North Andover
System Pumping Record
OCT2025
Form 4 -
DEP has provided this form for use by local Boards of Health. Other fornkik*ith W
information must be substantially the same as that provided here. Before using this or , A&entour
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 155 Laconia Circle
key to move your Address
cursor-do not North Andover MA 01845
use the return
key. City/Town State Zip Code
VC] 2. System Owner:
Paula MacDonald
&A Name
Address(—if different from--- --- --- -------location)- -- —- -----------
City/Town 1. -State .p Code----------------
978-337-3317
Telephone Number
B. Pumping Record
. Date of Pumping .9/22/2025 1500
1
D-ate- 2. Quantity Pumped: Gallons ----------
3. Type of system: F-1 Cesspool(s) Z Septic Tank R Tight Tank El Grease Trap
El 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
.......... ............
9/22/2025
Si ure of Hauler Date
.................
Signature of Receiving Facility Date
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