HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 81 BRADFORD STREET 9/4/2025 Commonwealth of Massachusetts Town
of IVOrth 4 n do Ver
City/Town of North Andover
System Pumping Record OCT 6 2025
Form 4
H myo,9P
DEP has provided this form for use by local Boards of Health. Other formea s
information must be substantially the same as that provided here. Before using this lflorm, c Otith 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 81 Bradford 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:
Susan Chary
6M Name
------ -Address(if different from--location}--,'" "-"- ---------
State Zip Code
978-683-5280 978-621-2675
Telephone Number -
B. Pumping Record
1. Date of Pumping 9/4/2025 2. Quantity Pumped: 1500 --------------
Date Gallons
3. Type of system: El Cesspool(s) Z Septic Tank n Tight Tank F1 Grease Trap
n Other(describe): ...................
4. Effluent Tee Filter present? Yes Z No If yes, was it cleaned? Yes Z 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
....................... ....................................
9/4/2025
eS of Hauler -bate
------------------------
Signature of Receiving Facility Date
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