HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 85 OGUNQUIT ROAD 5/12/2026 ' Commonwealth of Massachusetts
City/Town of North Andover
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 CIVIR 15.351. Town ol Wh over
A. Facility Information
Important:When JUN 9 -
filling out forms 1. System Location:
on the computer,
use only the tab 85 Ogunquit Road
key to move your Address
cursor-do not North Andover MA 01845-1470
use the return --111--l-1------- --------- ---------- ------
key. City/Town State Zip Code
VQ 2. System Owner:
Elizabeth Reger
-Kam'e------ ......................................................................................................................
Address(if different from location)
---------------------
City/Town State Zip Code
401-559-3484 603-682-9986
Telephone Number
B. Pumping Record
1. Date of Pumping Date 5/12/2026 2. Quantity Pumped: 1500 Gallons -------
3. Type of system: F1 Cesspool(s) Septic Tank R Tight Tank El Grease Trap
El Other(describe): .......... .............
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? 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
........................................
i�i5/12/2026
ure of Hauler Date
.......--------------- ----
Signature of Receiving Facility Date
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