HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 187 STONECLEAVE ROAD 6/2/2026 "I-owIn of Noftin over
Commonwealth of Massachusetts
City/Town of North Andover JUL 2 12026
System Pumping Record
Form 4 �'Iel�alith Department
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 CMR 15.351.
............
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 187 Stonecleave Drive
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:
Erin Carcia
Name
Address(if different fromm
.......................................... ............ .............
State Zip Code
617-201-6024
Telephone---Number
-
B. Pumping Record
6/2/2026 1500
1. Date of Pumping Date._.__.____ 2. Quantity Pumped: Gallons
3. Type of system: n Cesspool(s) Septic Tank n Tight Tank n Grease Trap
n Other(describe): ................ ......
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes No
5. Condition of System:
Good......., system operating properly
11....... ..-...............
6. System Pumped By:
Jason Elliott S71437 or V85257
�arn..e ...................................... .........
Vehicle License Number .
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
---------
6/2/2026
eise of-Hauler Date
------------------------
Signature of Receiving Facility Date
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