HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 148 CROSSBOW LANE 11/10/2025 Commonwealth of Massachusetts Town of Notl Andove,
City/Town of North Andover
System Pumping Record NOV 10 2025
Form 4
DEP has provided this form for use by local Boards of Health. Other f fftn
information must be substantially the same as that provided here. Before OTT,"check WL 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 CMR 15.351.
A. Facility--Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 148 Crossbow Lane
-----------
key to move your Address
cursor-do not North Andover MA 01845-3038
usethe return ----------- ......................... ..................................................... ..............----.....................................-------------
key. City/Town State Zip Code
VQ 2. System Owner:
Andrew Cournoyer
-----------................. ..........
Name
-Address--(if different from-- -location)
.............. ...................... - ........ .................................
City/Town State Zip Code
339-221-1058
Telephone Number
B. Pumping Record
1. Date of Pumping 10/13/2025 2. Quantity Pumped: 1500 ..............................
late....................te Gallons
3. Type of system: ❑ Cesspool(s) Z Septic Tank R Tight Tank F1 Grease Trap
F-1 Other(describe): .............. .................................-- -.1-1 - -1-11-1------- ......................
4. Effluent Tee Filter present? Yes 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
7. Location where contents were disposed:
GLSD
10/13/2025
. ...........................................................
-es' ---------re of Hauler Date
. . ..................... ....................................................................................................... ................... ....................
Signature of Receiving Facility Date
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