HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 800 JOHNSON STREET 4/23/2026 Commonwealth r�� Massachusetts��f� ~��xu� �� ��°���
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System Pumping Record ��� � � uv�°
Form 4
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OEP has provided this form for use by local Boards of Health, 0thA~V&01M sed. 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 nr other approving authority within 14 days from the pumping date in
accordance with 310 CyVIFl 15.351.
A. Facility Information
Important:When
filling Out forms 1. System Location:
on the computer,
use only the tab 800 Johnson Street
key m move your xudpeua
cursor-do not
North Andover MA 01845-3008
use the return ---------
koy, City/Town ~`~`~ Zip Code
2. System Owner:
=---" Stephen Bb
erry
ame
ot y/lown state zip Code
603-702-0238
B. Pumping Record
1. Date of Pumping 4/23/2028 2� Quantity Pumped: 1500
DateGallons
3. Type ofsystem: Cesspool(s) Septic Tank Tight Tank R Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? XYes No |f yes, was iicleaned? XYes El No
5. Condition of System:
Good, system operating properly
O. System Pumped By:
Jason Elliott S71437 orV85257
Name Vehicle License Number
|veetorend Elliott Services LLC-DBAJmson
B|ioU Pumping
7. Location where contents_ were disposed: