HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 347 HILLSIDE ROAD 4/1/2026 Commonwealth of Massachusetts Town of North Andover
p City/Town of North Andover MAY -- 6 Z026
System Pumping Record
Form 4
Health Department
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 347 Hillside Road
........... — ----------
key to move your Address
cursor-do not North Andover MA 01845
use the return ...............
key. City/Town State Zip Code
2. System Owner:
Matthew LaBerge
... .................
Name
- —--Address-'(if--d-if'f-ere—nt from-location}
City/Town State Zip Code
7
978-975-1087 603-494-1026
.. ...........................................................................
Telephone Number
B. Pumping Record
1. Date of Pumping 4/1/2026 2. Quantity Pumped: 1500 ........
Dat e-- - --- -- Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
R Other(describe): .......
4. Effluent Tee Filter present? Yes 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
1-111-111111................... .................. ------------.................. ..........
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
4/1/2026
--- ----------Si r Date
Signature of Receiving Facility Date
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