HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 235 OLD CART WAY 3/17/2026 �� Commonwealth Massachusetts
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System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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 Bound of Health or other approving authority within 14 days from the pumping date in
accordance with 318 CyVIR 15.351.
A~ Facility Information
Important:When
filling out forms 1. System Location:
un the computer,
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key mmove your Address
cursor do not
North Andover MA 01845
use the return
key. City/Town ~~ Zip Code
2. System Owner:
^--~ Scott Zemeri
Name
wn State Zip Code
978-314-2937
B. Pumping Record
3V17/2026 1500
1 D�he ofPumpin� 2 Quantity Pumped:
oam � � Gallons
3. Type ofsystem: Cesspool(s) Septic Tank R Tight Tank F] Grease Trap
R Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes No
S. Condition of System:
Good, system Uproperly
S. System Pumped By:
Jason Elliott S71437nrV85257
mame "vehicle License Number
|vestorond Elliott Services LLC-DBAJammn
Elliott Pumping
7. Location where contents were disposed:
GLSD