HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1 PENNI LANE 12/23/2025 Commonwealth of Massachusetts Tul Andover
p City/Town of North Andover
System Pumping Record
Y p� g
w Form 4
DEP has provided this form for use by local Boards of Health. Oth'A&ms niay be used, e
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 CMR 15.351.
A. Facility Information � 'own Of
r, rth____._____...... -�
Andover
Important:When
filling out forms 1. System Location:
on the computer, JAN 026
use only the tab 1 Penni Lane
key to move your Address
cursor-do not North Andover MA use the return 01845-6208
- a ---
key. City/Town State
r�
2. System Owner:
Daniel Tucci
Name
_ -----------------
Address(if different from location)
_.. ---- — __ ... ........ ..............
City/Town State Zip Code
617-816-7603
Telephone Numb 11 er
B. Pumping Record
12/23/2025 1500
1. Date of Pumping Gall_ 2. Quantity Pumped: .._........._._....................................._.__._._.._...._..__.
Date Gallons
3, Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -- ----._.
4. Effluent Tee Filter present? X Yes ❑ No If yes, was it cleaned? X 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
12/23/2025
Si ure of Hauler Date
Signature of Receiving Facility Date
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