HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 703 MIDDLETON STREET 9/24/2025 _
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System ��u����~n�� ��ec��rd ' �"`�
Form 4 Health
Department
DEP has provided this form for use by local Boards of Health. [)therforms may bm used, but�he
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 31OCMR1S.351.
A~ Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 7U3 Middleton Roed
xeymmove your Address
cursor do not
North Andover MA O1�45-0341
use menyum
key. City/Town State Zip Code
2. System Owner:
�---~ (5/nwecki
a me
ity/Town State Zip Code
781-215-1436
Telephone Number
B. Pumping Record
8/24/2O�� 1�0O
1. Date of Pumping �� Uuantih/ Pump�d�
3. Type ofsystem: Cesspool(s) Septic Tank El Tight Tank El Grease Trap
[l Other(describe):
4. Effluent Tee Filter present? Yes Z No |f yes, was itcleaned? Yes Z No
5. Condition ofSystem:
Good, system operating properly
G. System Pumped By:
Jason Elliott �7143� orV8��57
Name Vehicle License Number
/vee1ar and Elliott Services LLC-OBAJason
B|iottPumping
7. Location where contents were disposed:
GLGD
9/24/2025
ignature of Receiving Facility Date
t5fonn4.uoc0306 System Pumping Record^Page 1of11