HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1353 SALEM STREET 5/28/2026 1,
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.
A. Facility Information
Important:When
filling out forms 1. System Location: Town of North Andover
on the computer,
use only the tab 1353 salem Street
.................
key to move your Address .............. ...............
cursor-do not JUN 9 - 2026
North Andover MA 01845
use the return
key. City/Town State Zip Code
2. System Owner: Health Departrnent
James Keefe
..Name
................. -------Address(if different from location)
State .........................
.......................... ..
.. .... ............... -- - Zip Code
City/Town
978-821-2720
Telephone Number
B. Pumping Record
1. Date of Pumping 5./.2.8./"`2.026..-..-.--.-______..__.__ 2. Quantity Pumped: 1500
DateGallons
3. Type of system: R Cesspool(s) Septic Tank R Tight Tank F] Grease Trap
[I Other(describe): .11-111-1-11 ........... ----------------------- ........... .................. ..........-
4. Effluent Tee Filter present? X Yes ❑ No If yes, was it cleaned? X Yes E] No
5. Condition of System:
Good, system operating properly
..........................
6. System Pumped By:
Jason Elliott S71437 or V85257
N�am-e - -------------- ---- V-'ehic-le-Licen-s-'e- Nunn-ber---------------
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
5/28/2026
Si ure of Hauler Date
.............
Signature of Receiving Facility Date
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