HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 49 CARLTON LANE 9/19/2025 (3) Commonwealth of Massachusetts Town of N'0�tj AndOver
City/Town of North Andover OCT 2025
System Pumping Record
Form 4 Health Department
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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 310 CM R 15.351
---------- ........
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab -4-9-Carlton Lane ............ -—------------------ ......
key to move your Address
cursor-do not North Andover MA 01845-5602
use the return
key. City/Town State Zip Code
4:1 2. System Owner:
Joseph N icola isen
Name
Address(if different from location)
..........................
City/Town State Zip Code
781-367-3275
Telephone Number
B. Pumping Record
9/19/2025 1500
1. Date of Pumping _...... It.a e 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Z Septic Tank El Tight Tank n Grease Trap
n Other(describe): ---
4. Effluent Tee Filter present? Yes 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
9/19/2025
-S Nilyngure— of Hauler Date
Signature of Receiving Facility Date
t5form4.doc-03/06 System Pumping Record -Page 1 of 11