HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 659 FOREST STREET 9/9/2025 Commonwealth of Massachusetts A
��'fvyT �� hJ North Andover
--�s��
����y/ / []��[] ��/ / n��. �/ /S �r
/
°������� ������~�� �����D�� '6 2025
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may
information must be substantially the same as that provided here. Before using this form. rh604th 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 dmba in
accordance with 31OCIVIR15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab `
key mmove your Address
cursor do not
North Andover MA 81864
use the return -----
k*v. City/Town State Zip Code
2. System Owner:
~---~ A|iokaei Zhy I inski
Nam*
city/Town State Zip Code
857-928-9394
B~ Pumping Record
9/9/2025 1500
1� Date ofPumping bate 2. Quantity Pumped: Gallons
3. Type wfsystem: n Cesspool(s) Septic Tank n Tight Tank [l Grease Trap
n Other(describe):
4. Effluent Tee Filter present? Yea No |f yes, was itcleaned? Yes No
5. Condition of System:
Good, system operating properly
S. System Pumped By:
Jason Elliott S71437urV85257
Name Vehicle License Number
|veg1erand Elliott Services LLC-OBAJaeon
Elliott Pum i
7� Location where contents were disposed:
GLSD
9/9/2025
Signemmw Receiving Facility oaua