HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 200 CANDLESTICK ROAD 7/19/2023 Commonwealth of Massachusetts
City/Town of No. Andover 19'Loti
System Pumping Record
Form 4
M
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. Befcre 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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the only
the tab
J/
use only the tab (J (,F�j�t C�(
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
Name
raam
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record 0(9
1. Date of Pumping 2. QuantityPumped:
Date p Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes W No If yes, was it cleaned? ❑ Yes [jrNo
5. Observed ndit' of omponent pumped:
611
6. Sys q pped yc By.
Name Vehicle Li dense Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 radford,MA
Signa ure o Date
Signature of Receiving Facility(or attach facility receipt) Date
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