HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 182 OLYMPIC LANE 12/17/2025 T OWn of'V"th4ndOVer
Commonwealth of Massachusetts
p City/Town of North Andover
JAN
System Pumping Record
Form 4 Hea,,,, 1Depaj,,,,,t
DEP has provided this form for use by local Boards of Health. Other forms may be used, but
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 182 Olympic Lane
.............I--------------- -------------
key to move your Address
cursor-do not North Andover MA 01845
use the return -Cit I y 1.T-o I w 11 n ............... State ............. Zip Code
key.
Q2. System Owner:
Christopher Lindsey
--------Name -—-----------------................----- ------- -------------
reaxn
-;k-d&ress(if diffe
rent from-—location)
—----------------------------
City/Town State Zip Code
802-345-9151
Telephone Number
B. Pumping Record
1. Date of Pumping 12/17/2025 2. Quantity Pumped: 1500
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
F] Other(describe):
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
12/17/2025
-m' —'r'-of, a-uler Date --------
--------............... ..........................................
Signature of Receiving Facility Date
t5form4.doc-03/06 System Pumping Record-Page 1 of 7