HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 PENNI LANE 11/10/2025 Commonwealth of Massachusetts 17 00V
� City/Town of North Andover aver
System Pumping Record Nov 10 2025
Form 4
DEP has provided this form for use by local Boards of Health. Other forms aq4u& but the
information must be substantially the same as that provided here. Before using this for your
local Board of Health to determine the form they use. The System Pumping Record must be sV to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 42 Penni Lane
----------....... ............... ...........................
key to move your Address
cursor-do not North Andover MA 01845-6209
use the return ..........--........................ - - -......................--
key, City/Town State Zip Code
VQ 2. System Owner:
Matthew Savory
Name
..............
Address(if different from location)
al-ly/-To wn--- 'S"taie---- - ----- -Zip-C Cade---
---e---
978-609-8254
Telephone- - - - Number ---------B. Pumping Record
1. Date of Pumping .10/7/2025 2. Quantity Pumped: 1500
Date Gallons
3. Type of system: El Cesspool(s) Z Septic Tank F1 Tight Tank r-1 Grease Trap
R Other(describe):
4. Effluent Tee Filter present? Yes Z No If yes, was it cleaned? Yes Z No
5. Condition of System:
Good, system operating properly
............-.......... ........................... ........ ..............I...........-.................................................................................................. ..............................
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
... . . ........................ ........................... ...............--------------------------------------------- . ... . ..................................................
10/7/2025
Si ure of Hauler .....................
Signature of Receiving Facility Date
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