HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 165 BOSTON STREET 6/23/2026 Commonwealth of Massachusetts V�1/11 Of North Andover
I City/Town of North Andover JUL 2 12026
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be u9c'e9j;9rttMent
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.
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A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 165 Boston Street
.......................
key to move your Address
cursor-do not North Andover MA 01845
use the return ........................ ---
key, City/Town State Zip Code
2. System Owner:
Eric Lynch
. ..................................
ame
Aad'r`es's`-(-if"-difff-e-r—ent-—fro—mic-c—atio'n")............................................. ..................................
a- ------ --- - ---- - -- - - ------ -- - -- ................
ity/Town State Zip Code
978-807-6348
lephone Number
B. Pumping Record
6/23/2026 1500
1. Date of Pumping .......__ 2. Quantity Pumped: ............
Gallons
3. Type of system: Cesspool(s) Septic Tank n Tight Tank F1 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
6� System Pumped By:
Jason Elliott S71437 or V85257
lum- Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumping
-----.........
7. Location where contents were disposed:
GLSID
6/23/2026
O�Si7orure of Hauler Date - ................ ------------------------------
........................................ ----------
Signature of Receiving Facility Date
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