HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 2005 SALEM STREET 5/28/2026 Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
ki Piz" 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
A -cfNaZA A. Facility Information hdover
Important:When
filling out forms 1. 'System Location:
on the computer, JUN 9 - 2026
use only the tab .2005 Salem Street
key to move your Address
cursor-do not North Andover _-3332
use the return ... ............................... ..................... m./H-e-calth Depart
key. City/Town State M®rp Pfda e
VQ 2. System Owner:
Andrew Tenney ----------- -
Name.
I m I e
Address --------. ---................. ------ - ..... .. ... ...------------------ ---------- .......... ........... ........... ........ . .................... .................
(if different from location)
............... . ............
—City/Town ----------------------- State Zip Code
339-227-0482
Telephone Number
..........
B. Pumping Record
1. Date of Pumping .5/28/2026 2. Quantity Pumped: 1500
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank R Tight Tank F-1 Grease Trap
F] Other(describe): ................................................. .................----...........
4. Effluent Tee Filter present? X Yes ❑ No If yes, was it cleaned? X Yes ❑ No
5. Condition of System:
Good, system operating properly
......................... ........................................... . ...................................
6. System Pumped By:
Jason Elliott S71437 or V85257
.............--.......-.1.......................... ......... ....................
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
5/28/2026
-S ure of Hauler Date
............................... . ..................................
Signature ofReceiving FacilityDate
t5form4.doc-03/06 System Pumping Record-Page 1 of 6