HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 2 BRECKENRIDGE ROAD 6/22/2026 -71
I o�,Ajn of NMh Andover
Commonwealth of Massachusetts
il City/Town of North Andover JUL 2 12026
System Pumping Record
Form 4 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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 2 Breck-e....n....r...idge Road
......
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:
Sha Ding
Name
-Aad-ress-(--if-d-ifferent from location)
.................
— - -----
--------- - -----
).............. . ..--— - --- -- -- --- ---------------- --------------- -------------------------------
City/Town State Zip Code
540-750-3510
Telephone Number
B. Pumping Record
1. Date of Pumping -------6/22/2026 2. Quantity Pumped: 11.500----
Date Gallons
3. Type of system: ❑ Cesspool(s) Z Septic Tank R Tight Tank r-1 Grease Trap
El Other(describe): --1--111-............................. ........--- --------
4. Effluent Tee Filter present? Yes Z No If yes, was it cleaned? Yes M No
5. Condition of System:
Good, system operating_properly_
...pr�
6. System Pumped By:
Jason Elliott S71437 or V85257
.......................------ .......................................
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
........... -I- ------
7. Location where contents were disposed:
GLSD
............ -------------------
6/22/2026
Si ure of Hauler Date
................ .......................... - ...................................
Signature of Receiving Facility Date
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