HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 415 WINTER STREET 11/6/2025 Commonwealth Massachusetts
������������\�����/u / ��/ /v/��������(�/ /[]���~���
y�'+uy� � �� vf� Andover
�����/ : ��VV�] ��/ North/ ��[1��o\/er
����s���� �������.��� ��������
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 ba 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 |uco| Board of Health or other approving authority within 14 days from the pumping date in
accordance with 318CK4R15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 416VWnterStn��t
key to move your Address
cursor do not
North Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
^---~ Francesca Grimaldi
Name
078-771-9953
Telephone Number
B. Pumping Record
1. Date ofPumping Dote 11/6/2025 2. Quantity Pumped: 1500
Gallons
3. Type ofsystem: [l Cesspool(s) Z Septic Tank R Tight Tank [l Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? Yes Z No |f yes, was iicleaned? Yes Z No
5. Condition of System:
Good, i |
G. Sva&*m Pumped By:
Jason Elliott S71437orV85267
Name Vehicle License Number
|vea1mrmnd ElliottServices LLC-DBAJuson
Elliott Pumping
7. Location vvhen* contents were disposed:
BLSU