HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 67 ROCKY BROOK ROAD 9/9/2025 Commonwealth of Massachusetts TO Wn Of Aforb,�4 n do Ver
City/Town of North Andover
OCT
System Pumping Record
. 205
Form 4
DEP has provided this form for use by local Boards of Health. Other forms I!�Sft with
information must be substantially the same as that provided here. Before using this form, M 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 67 Rocky Brook Road
-----------------
key to move your Address
cursor-do not North Andover MA 01845
use the return .................................... ... ...... ——------------------
key City/Town State Zip Code
2. System Owner:
Jay Huapaya
Name-
Address(if different from location)
City/Town
Cod
------------------
own State Zip e
978-697-1842 978-688-8489
Telephone Number- -- ------ -- -- - -
B. Pumping Record
9/9/2025 1500
1. Date of Pumping .............a t.e.................................................................. 2. Quantity Pumped: Gallons .................
3. Type of system: F-1 Cesspool(s) Septic Tank ❑ Tight Tank n Grease Trap
n Other(describe): .........................
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes E 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
— -—-- ---------- .....................................................................
9/9/2025
S,e— of Hauler Date
Signature of Receiving Facility Date
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