HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 295 CAMPBELL ROAD 11/10/2025 Commonwealth of Massachusetts
City/Town of North Andover
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 date in
accordance with 310 CIVIR 15.351.
A. Facility Information
Of AlOrth Andover
Important:When
filling out forms 1. System Location:
on the computer, NO V 10 2025
use only the tab 295 Campbell Road
key to move your Address
cursor-do not North,Andover MA 0 1845-5700
use the return
key. City/Town State epai��t -
e---I) 2. System Owner:
Robert Bambury
......... ....
Name
..................................................................
Address(if different from location)
..........-—--——---------------------
City/Town- State Zip Code
1-978-687-1825 978-979-0134
Telephone Number
B. Pumping Record
10/28/2025 1500
1. Date of Pumping 2. Quantity Pumped: ............... ------------
Date-------- Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank n Tight Tank El Grease Trap
nOther(describe): -1-1.--- ................... .................................................................................................--------...............................................
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes 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:
GLSD
10/28/2025
Si of Hauler Date
Signature of Receiving Racility Date . .................................................................................. .. .... ...............
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