HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 254 LACY STREET 12/10/2010 Commonwealth of Massachusetts Town of North Andover
p City/Town of North Andover
System Pumping Record
Form 4 JAN -6, 21]10 LP
DEP has provided this form for use by local Boards of Health. Other for b ed, but the
'or
information must be substantially the same as that provided here. Befomsgaci&; �ur
local Board of Health to determine the form they use, The System Pumping Record mustto
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 254 Lacy Street
................ ---------- ----------------------- .............. ...............
key to move your Address
cursor-do not North Andover MA 01845
use the return ---------------- ................. -- ----------------------- - - — ---------
key. City/Town State Zip Code
VQ 2, System Owner:
Tanveer Ahad
Name
..............
Address(if different from location)
--okyffown— State Zip Code
617-606-2810
Telephone
eIepInone Number
B. Pumping Record
12/10/2025 1500
1. Date of Pumping
_._at_........._.._............................... 2. Quantity Pumped: Gallons ............................
3. Type of system: ❑ Cesspool(s) Z Septic Tank n Tight Tank F1 Grease Trap
F 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
12/10/2025
of Hauler -bate---- --- -- . ...... .................... .............. ------------------
Si
..............................
Signature of Receiving Facility Date
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