HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 51 WELLINGTON WAY 12/11/2025 Commonwealth ,�f Massachusetts��+f� «o:v'« o/ «V�/[tXAndover
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System � � �°��� �DSystem Pumping Record ~~.�8N
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Health De rt ����
DEP has provided this form for use by local Boards of Health. Other forms may��us6df-5bl�he
information must be substantially the aanoo as that provided here. Before using this form, check with your
local Board of Health tm 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 31OCyWR15.351.
A. Facility Information
Important:When
filling out vunns 1. System Locution:
un the computer,
use only the tab 51 Wellington Way
key oo move your Adumea
cumor-do not
North Andover MA 01845
use the return
key. ~11'11^'''~`~' State Zip~ode
2. System Owner:
~---� Anno/Uibedi
Name
Address(if different from location)
ity/Town State Zip Code
978-482-6647
B. Pumping Record
1. Date ofPumping Date12/11/2O25 2. Quantity Pumped: 1500
Gallons
3. Type ofsystem: M Cesspool(s) Z Septic Tank M Tight Tank Fl Grease Trap
El Other(describe):
4. Effluent Tee Filter present? Yea Z No |f yes, was i1cleaned? Yes Z No
5. Condition ofSystem:
Good system tiproperly
G. System Pumped By:
Jason Elliott S71437 or V85257
Name Vehicle License Number
|vesterond Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
12/11/2025
Signature or Receiving Facility Date
t5&onn4.Uuo^0305 System Pumping Record^Page 1ofT