HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 60 SAVILLE STREET 8/13/2026 Andover
Commonwealth Massachusetts �«m� '� �0�h
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System ��u�����ng Record "�' ° ^~�"
Form 4
M����h �D� /t ment
DEP has provided this form for use by |oom| Boards of Health. Other forms � used, t 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 |Ooa| Board of Health or other approving authority within 14 days from the pumping dote in
accordance with 310 CyVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
SS Saville Street vovon��*�b /
keymmove your Address
u"mo,-do not
North Andover MA 01845-6158
use the return
key. City/Town ~`~`~ Zip Code
VOA2. System Owner:
^---~ Kevin Finn
Name
Address(if different from location)
ity/Town State Zip Code
617-775-0652
B~ Pumping Record
1. Date of Pumping 8/13/2026 2� Quantity Pumped: 500
DateGallons
3. Type nfsystem: Fl Cesspool(s) Septic Tank n Tight Tank Fl Grease Trap
n Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yea No
5. Condition of System:
-Pump chamber | Good, system operating |
6. System Pumped By:
Jason Elliott S71437 orV85257
Name Vehicle License Number
|vesterand Elliott Services LLC-DBAJamun
B|iottPumping
7. Location where contents were disposed:
GLSO
8/13/2026
_esig_ ure of Hauler------- Date
Signature of Receiving Facility Date
t5form4.don`0300 System Pumping Record^Pago 1 of