HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 295 FOREST STREET 5/7/2026 Commonwealth of Massachusetts Town of Noah Andover
City/Town of North Andover
System Pumping Record JUG 9 - 2026
Form 4
DEP has provided this form for use by local Boards of Health. Other f b information must be substantially the same as that provided here. Bef =t[Q*,VWh 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.
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A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 295 Forest Street
.......... . ............................. .......................
key to move your Address
cursor-do not North Andover MA 01810-3207
use the return - ---__-_---
key. City/Town State Zip Code
2. System Owner:
William Ferrucci
Name
Address(if-different from location)-- ---- ...................
..........._................. ................... ---- ............
City/Town State Zip Code
603-321-1293
Telephone Number
B. Pumping Record
1. Date of Pumping .5/7/2026 .......... 2. Quantity Pumped: 1500
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank n Tight Tank El Grease Trap
nOther(describe): ........................................................ .................11.............................. ............................
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
Na-me Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
-----...............
7. Location where contents were disposed:
GLSD
........................... ................................ .............
5/7/2026
Si ure of Hauler Date—
............ .......... .......... ...... --------
Signature of Receiving Facility Date
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