HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 960 JOHNSON STREET 6/10/2026 Commonwealth of Massachusetts I"Own of North Andover
p 9 City/Town of North Andover
UL
System Pumping Record J 2 12026
Form 4
1-9';;'a i tI D&Dqhqm e n t
DEP has provided this form for use by local Boards of Health. Other forms may be used, t e
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 960 Street Johnson Strt
---------------------------- ------------------------------------------------------------------------------------------
key to move your Address
cursor-do not North Andover MA 01845
use the return ------------------------------ ..............................
key. City/Town State Zip Code
VQ 2. System Owner:
Jeremy Rocheford
Name -----------------
Address(if different from location)
--------------- .......... .......................
CitylTown State Zip Code
617-990-4619
Telephone Number
B. Pumping Record
1. Date of Pumping 6/10/2026 2. Quantity Pumped: 1500
Date Gallons
3. Type of system: ❑ Cesspool(s) E Septic Tank ❑ Tight Tank R Grease Trap
El Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes No
5. Condition of System:
Good, system operating properIY._
6. System Pumped By:
Jason Elliott S71437 or V85257
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott
umping
..................................... ---------
7. Location where contents were disposed:
GLSD
6/10/2026
Sig u—reof Hauler- Date
Signature of Receiving Facility Date
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