HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2201 SALEM STREET 4/15/2026 Commonwealth of Massachusetts Town of North Andover
(0 City/Town of North Andover
System Pumping Record MAY - 6 2026
Form 4
DEP has provided this form for use by local Boards of Health. Othe44%A@PA6tU3AW
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 CIVIR 15351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 2201 Salem Street
key to move your Address
cursor-do not North Andover MA 01845
use the return ............... .............. ..........
key, City/Town State Zip Code
2. System Owner:
Yi Kwan Wong
Name
................—---------------------- ....... .................. ............................. ..............
Address(if different from location)
. i —...................... . ........---11.11-111----------- ........diiown State Zip Code
978-996-9990
--e1—ep -
WN
B.-Pumping Record ...
1. Date of Pumping 4/15/2026 2. Quantity Pumped: 1500 ..................
ba�ie-....................— Gallons
3. Type of system: F-1 Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
n 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
..................................--------------------------------------- ............... ...........
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
-----1- - -
7. Location where contents were disposed:
GLSD
.................................................................... ........... ........... ............
4/15/2026
Si rure of-H a Date
ate
............................... - ..................... ----------- .........
Signature of Receiving Facility Date
06 System Pumping Record-Page 1 of 5