HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 134 OLYMPIC LANE 8/4/2026 Commonwealth of Massachusetts Town of Not Andover
City/Town of North Andover SEP 9 2026
v "� 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 134 Olympic Lane
key to move your Address
cursor-do not North Andover MA 01845-3314
use the return
key, City/Town State Zip Code
4D2. System Owner:
Theresa Hardy
'Name
ream
... -- ... ......Address
.................----- . .................... .......
ress(if different from location)
City/Town- -,State---- - -Zip Co-de"',-----",
978-258-96 93 978-2 39-6 059
Telephone-Number
B. Pumping Record
8/4/2026 1250
1. Date of Pumping . .......... .......................- ------ 2. Quantity Pumped: _......................
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank n Grease Trap
n Other(describe): ------ -------------
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes E 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
8/4/2026
i ure of Hauler Date
.......... ...................
Signature of Receiving Facility Date
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