HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 234 BRIDGES LANE 1/2/2025 Commonwealth of Massachusetts Town of Nofth Andover
City/Town of No Andover
System Pumping Record FEB 3 U25
Form 4
DEP has provided this form for use by local Boards of Health. Ok Llze&
information must be substantially the same as that provided here. Before us"ingt ilsvowwith 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
key to move your Address (7
cursor-do not
use the return
key. City/Town State Zip Code
2. System Owner:
ratr
Name
reaan
Address(if different from location)
No Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date/ 2. Quantity Pumped: Gallons
3. Component: Cesspool(s) eptic Tank Tight Tank Grease Trap
Other(describe):
4, Effluent Tee Filter present? ❑
Y&—s Na If yes, was it cleaned? 0 Yes E] Na
5. Observed condition of component pumped:
6. Sys talzqpump d By:
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
Signature of Haulef,�' Date
Signature of Receiving Facility(or attach facility receipt) Date
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