HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2060 TURNPIKE STREET 11/10/2025 Commonwealth of Massachusetts 'Vorth4t7dOver
ro City/Town of North Andover
NoV 10 2025
System Pumping Record
Form 4 D
!P,
DEP has provided this form for use by local Boards of Health. Other forms may be use 15RAMent
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
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 2060 Turnpike
------------------------------------------------------- ................................. ........... ............. ------------ .................... ................
key to move your Address
cursor-do not North Andover MA 01845
use the return -----------------------
key. City/Town State Zip Code
2. System Owner:
Mansour Khani
Name .........................
Address(if different from location)
cdwfon State Zip Code
978-853-6987
ie p I ho-n 11 e--Number
--- - I .. . ....................
B. Pumping Record
1. Date of Pumping 10/20/2025 2. Quantity Pumped: -1500
Gallons
— - --.... ............Date
3. Type of system: M Cesspool(s) Z Septic Tank F-1 Tight Tank [:1 Grease Trap
ROther(describe): .........................................................................................1 -1-1-1-1 ....................................................---
4. Effluent Tee Filter present? Yes Z No If yes, was it cleaned? Yes Z 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
11 111,1111 1 11........... ................................---------.......................................
7. Location where contents were disposed:
GLSD
10/20/2025
.
Si ure of Hauler ........... ........................ ...................---................................ Date
- -- -- ...
- ........................
Signature of Receiving-Facility, Date
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