HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 101 BRIDGES LANE 10/15/2025 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
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 101 Bridges Lane
............... ------
key to move your Address
cursor-do not North andover MA 01845-2220
usethe return - —------------- ........... ...........----.......... ..........................—
key. City/Town State Zip Code
2. System Owner:
Stephen Cammarata
---------------------- . . . ...................................................
Name
................... ............
Address(if different from location)
City/Town State Zip Code
617-913-1726
It e I e p h on e Number
B. Pumping Record
1. Date of Pumping 10/15/2025 2. Quantity Pumped: 1500
-ba't e.....................--- G�-Ifoas.... ..........................................
3. Type of system: F-1 Cesspool(s) Z Septic Tank R Tight Tank R Grease Trap
ROther(describe): .............................. .......... ...............................................
4. Effluent Tee Filter present? X Yes ❑ No If yes, was it cleaned? X Yes ❑ No
5. Condition of System:
Good, system operating properly
.......... -------
6. System Pumped By:
Jason Elliott S71437 or V85257
..............I----------------------- ................. ............................................
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
................... - —- - -------------------------------------------------
10/15/2025
-e� of Hauler Date
..................................... .................... . .. ............................................................................................................. ...... ........................
Signature of Receiving Facility Date
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