HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 99 OGUNQUIT ROAD 6/2/2026 Commonwealth of Massachusetts Andover
City/Town of North Andover JUL 2 12026
System Pumping Record
Form 4
1(:;a1tin 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 CM R 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 99 Ogunquit Road
.............-- ............... -------------------
key to move your Address
cursor-do not North Andover MA 01845-1470
use the return ------------------- ................ ....................... ---
key. City/Town State Zip Code
41 2. System Owner:
Ivett Lafave
Name
Address(if different from location)
--.---------- ...........
City/Town State Zip Code
978-239-7744
Telephone Number
B. Pumping Record
1. Date of Pumping .6/2/2026 ......................... 2. Quantity Pumped: 500 .......................
ba-te- �-- Gallons
1 Type of system: Ej Cesspool(s) Z Septic Tank Fj Tight Tank F-1 Grease Trap
nOther(describe): ...................... ........................--........................
4. Effluent Tee Filter present? Yes Z No If yes, was it cleaned? Yes Z No
5. Condition of System:
Good, system operating properly
.............. ------ -----------
6. System Pumped By:
Jason Elliott S71437 or V85257
.......................----------------------
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
7. Location where contents were disposed:
GLSD
............ ................. .............------------................ ........................ - ------
6/2/2026
-m3iure of Hauler------------------------------------------------............................... -Date
11-. ..................
------------------
Signature of Receiving Facility Date
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