HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 32 PADDOCK LANE 1/5/2026 Commonwealth ����
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System Pumping Record FEB - % 2026
Form 4
DEP has provided this form for use bv local Boards of Health. Dth
information must beaubatantiaUy the same as that provided here. BMeIising 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 310CyVIR15.351.
A~ Facility Information
Important:When
filling out forms 1. 3vmbsm Location:
on the computer,
use only the tab 32 Paddock Lane
keym move your Address
cursor do not
North Andover MA 01845
use the n:tum
key. City/Town State Zip Code
2. System Owner:
~---� JasonKubeneki
Name-
Address
City/Town State Zip Code
617-791-5532
Telephone Number
B. Pump~ng Record
1. Date ofPumping 01/5J2028 2� Quantity 1500
DateGallons
3. Type ufsystem: F� Cesspool(s) E Septic Tank F-1 Tight Tank n Grease Trap
n Other(describe):
4. Effluent Tee Filter present? Yes NV |f yes, was itcleaned? Yee No
5. Condition of System:
Good, system tiproperly
6. System Pumped By:
Jason Elliott S71437orV85267
Name Vehicle License Number
|veater and Elliott Services LLC-DBAJason
Elliott Pumping
7. Location where contents were disposed:
GLSO
01/5/2026
ure of Hauler Date
5Si -
Signature of Receiving Faci ooto
t5fo,m4,duo^03/00 System Pumping Record`Page 2of2