HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 555 BOSTON STREET 11/24/2025 Commonwealth
��{����1��[l\�Ke��/w / ^�/
��'fw/� � MJ North Andover
���uy/ ^ ����D ��/ /~[]/ �/ / r���`�o\/er
System Pumping Record
Form 4
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 dote in
accordance with 31OCyVIF< 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 555 Boston Street
*eymmove your Address
cursor do not
North Andover MA 01845-6320
use the return
key. City/Town State Zip Code
1 Svabnm Owner:
~---� Geoffrey Bond
Name
Address(if different from location)
ut /own State �ipCod�
857-600-7525
Telephone Number
B. Pumping Record
11/24/�O�� 1�00
1. Date ofPumping 2 Quantity
Date � � Gallons
3. Type ofsystem: |l Cesspool(s) E Septic Tank F1 Tight Tank El Grease Trap
R Other(describe):
4. Effluent Tee Filter present? Yes Z No If yes, was dcleaned? Yes Z No
5. Condition of System:
Good, operating
S. System Pumped By:
Jaaon Elliott S71437 orV85257
Name Vehicle License Number
|veater and Elliott Services LLC-DBAJason
-Elliott Pumping
7. Location where contents were disposed:
GLSD