HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 143 LIBERTY STREET 3/5/2026 Commonwealth of Massachusetts
City/Town of North Andover
9.LL g 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 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 143 Liberty Street
I--I I.............. ........re et ........................................----_- --------__-_- -- -_-------------
key to move your Address
cursor-do not North Andover MA 01845
usethe return __- - . . ........................... ...................... —-- - --------__- ---
key. City/Town State Zip Code
2. System Owner:
Brian Mahoney
.........................................................................................
Name
...........
Address(if different from location)
awyaam ------------------- -State----- ------- -- zip Code ---------------_---_-_-
781-715-4732
Teie 1ph&n-eNumber —------------------- -------------- -
B. Pumping Record
1. Date of Pumping 3/5/2026 ........... 2. Quantity Pumped: 1500 ----------------------
baie-------------------------- . Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank [I Grease Trap
F] Other(describe): ...................................
4. Effluent Tee Filter present? X Yes ❑ No If yes, was it cleaned? X Yes E] 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
................... ...... ------ 3--/5/2026
...................................... ......................
%Siure of Hauler Date
_S;- __ __ - - -____ - - I I_____ I—— -----------
ignature of Receiving Facility Date
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