HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 292 GRANVILLE LANE 4/24/2026 Commonwealth of Massachusetts Town Of North over
_p City/Town of North Andover
MAY -6 System Pumping Record 2026
Form 4
Health Departme
DEP has provided this form for use by local Boards of Health. Other forms may be used,but thent
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 15.351.
................ ....................... ...........
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 292 Grandville
-—-------------------------------- --
key to move your Address
cursor-do not North Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner:
Earth Works Construction
Name
Wjjnes`s(if different f-,r'o'-'m location)
State- Zip Code
978-265-7320
Telephone Number
............
B. Pumping Record
1. Date of Pumping .4/24/2026 2. Quantity Pumped: .1500
Date Gallons
3. Type of system: ❑ Cesspool(s) E Septic Tank F] Tight Tank El Grease Trap
R Other(describe): ------
4. Effluent Tee Filter present? Yes M 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
7. Location where contents were disposed:
GLS D
4/24/2026
Si 6re of Hauler Date
- - - .... - - -- - -- - - -- - I I,,-,,,',,,----111.....
..
...........
Signature of Receiving Facility Date
t5form4.doc-03/06 System Pumping Record-Page 2 of 5