HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 115 JOHNNY CAKE STREET 12/31/2025 Commonwealth of Massachusetts 7b wn of Vorth 4 ndo Ver
p City/Town of North Andover
System Pumping Record JAN
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be
information must be substantially the same as that provided here. Before using this form, checgt 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 115 Johnny Cake Street
-11, .1111111.111-------------- ------ - --- - ---------------------------------------------- ....................................................................................................................
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:
Laura Sincerbeaux
Name
------------------------
Address(if different from location)
-City/Town------- Zip Code
910-988-9044 207-458-2726
Telephone Number
B. Pumping Record
1. Date of Pumping 12/31/2025 2. Quantity Pumped: 1500
Date Gallons
3. Type of system: ❑ Cesspool(s) E Septic Tank El Tight Tank n Grease Trap
F-1 Other(describe): ......................................... ..................-
4. Effluent Tee Filter present? Yes M 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
12/3 1/2025
Si ure of Hauler Date
Signature of Receiving Facility Date
t5form4.doc-03/06 System Pumping Record-Page 2 of 7