HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 OLD CART WAY 11/10/2025 Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4 of�qOrt,�AndOVer
DEP has provided this form for use by local Boards of Health. Other forms N"r Ii v d but the
information must be substantially the same as that provided here. Before using i 4�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 da*jrol,v, umping date in
accordance with 310 CIVIR 15.351. OPallment
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 30 Old Cart Way
.. ......................... - - - --------------__--__-__-------_---_-_---
key to move your Address
cursor-do not North Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
Amneet T a t1a
Name
Address(if different from location)---
City/Town State Zip Code
972-786-6027
Telephone Number
B. Pumping Record
1. Date of Pumping .10/7/2025 2. Quantity Pumped: 1500
_ --------------
Date --'- -_ Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank n Tight Tank F1 Grease Trap
nOther(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:
GLS D
10/7/2025
_tSXre_oi Date ............. ...............
Signature of-Receiving-F_a_di_1ity Date
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