HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 91 FARNUM STREET 12/18/2024 Commonwealth of Massachusetts Town of NOM Andover
City[Town of No Andover
FEB 3 2025
System Pumping Record
Form 4
Health De
DEP has provided this form for use by local Boards of Health. Other forms may be LIMP, 9 Mw n t
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
key to move your Address
cursor-do not
use the return
key. CitylTown State Zip Code
2. System Owner:
Address(if different from
No Andover MA
City/Town State Zip Code
Telephone-Number
B. Pumping Record
1. Date of Pumping 2 2. Quantity Pumped: ex')
Date G�Ions
3. Component: Cesspool(s) Septic Tank Tight Tank [] Grease Trap
L7 Other(describe): ............
4. Effluent Tee Filter present? ] Yes No If yes, was it cleaned? Yes E] No
.
5. Observed condition of com PP t Pumped:
IT
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic 68 So Kimball St.(, Bradford,MA
Company
T Location where contents were disposed:
20 SoMill St.,Bradford,MA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11/12 System Pumping Record•Page 1 of 1