HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 24 CROSSBOW LANE 8/10/2026 Town of North Andover
Commonwealth of Massachusetts
SEP
p, City/Town of North Andover 9 2026
Ewa System Pumping Record
Form 4 Health 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 24 Crossbow Lane
...........--__------ ---------------- --------------
key to move your Address
cursor-do not North Andover MA 01845-3036
use the return ------- ----- - - --------_----------------
key, City/Town State Zip Code
4:1 2. System Owner:
Neil Manning
Name
Address(if different from location)
City/Town State Zip Code
617-872-2471
Telephone Number-
B. Pumping Record
1. Date of Pumping 8/10/2026 2. Quantity Pumped: 1500
Date Gallons
3. Type of system: F] Cesspool(s) Septic Tank R Tight Tank ❑ Grease Trap
R Other(describe): _------ ------
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes E No
5. Condition of System:
-Back flushed 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
------------- --_------------
8/10/2026
Si ure of Hauler Date
-_-__-_------- -------_-------------- --_--_------_------- --------------------- ---_-_--------------
Signature of Receiving Facility Date
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