HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 456 SUMMER STREET 11/10/2025 Commonwealth of Massachusetts rot?,?Of n do Ver
F City/Town of North Andover Nov 10
System Pumping Record
Form 4
'e DEP has provided this form for use by local Boards of Health. Other forms may be use opbcL
information must be substantially the same as that provided here. Before using this form, check!qt1your
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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 456 Summer Street
................. ---------- ..................................... .......... ------- ............................... .........................
key to move your Address
cursor-do not North Andover MA 01845-5643
use the return ........... - - 1111-1-111.1-- --------------------------------------
key. City/Town State Zip Code
VQ 2. System Owner:
Donna Carlstrorn
-. -1--- I - 11 ----- -Name
-Ad—d r6ii-Cif 6-m--1 location) -------------
—--------- ......................-..........................-..................... ..........
State Zip Code
603-533-0664 978-686-2981
Telephone Number B. Pumping Record
1. Date of Pumping 10/28/2025 2. Quantity Pumped: 1500
Date Gallons
3. Type of system: F1 Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
ROther(describe): ........................................ ...............................................................--.-...................................... .....................
4. Effluent Tee Filter present? X Yes ❑ No If yes, was it cleaned? X Yes R No
5. Condition of System:
Good, system operating properl
....................�y_ .............
6 System Pumped By:
Jason Elliott S71437 or V85257
_ -1-1--.-11- .-..................................Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
.............. ................
10/28/2025
-Si%-----r--of Hauler, 'ba-te'--
ignature of Receiving Facility Date
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