HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 448 BOXFORD STREET 12/22/2025 Commonwealth of Massachusetts 'Tbwn Of IVOM)Andover
p City/Town of North Andover JA At -g 2021
System Pumping Record
D P,
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, butt qnt
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 .448 B-ax-ford Street.,...........................
key to move your Address
cursor-do not North Andover MA 01845
usethe return .1111111,11111111..............."I'll"-"""""�,�,,�. ,.-�,_.-.. 1 .�, -._,.,�'ll"�'ll""I...............
key. City/Town State Zip Code
VQ 2. System Owner:
Ryan Hale
Name
Address- ---(-if different- __ from location) ......
City/Town State Zip Code
315-345-6877 631-258-6808____________
Telephone Number
B. Pumping Record
1. Date of Pumping 12/22/2025 2. Quantity Pumped: 1500
Date Gallons
3. Type of system: ❑ Cesspool(s) Z Septic Tank El Tight Tank n Grease Trap
n Other(describe):
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
-------_-_..................... - . . ....................................................................
7. Location where contents were disposed:
GLSD
12/22/2025
Si ure of Hauler- —---------- Date
Signature of Receiving Facility Date
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