HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 369 SALEM STREET 1/16/2025 I\ Commonwealth of Massachusetts
City/Town of No Andover
wo, System Pumping Record
Form 4
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 x
key to move your Address
cursor-do not
use the return State
key. WWAnd0ver
Z System Owner:
Name
Address(if different from location)
No Andover MA Hcalf h Department
City/Town State Zip Code
Telephone Number
B. Pumping cord
M..1�
I. Date of Pumping -Date/ 2. Quantity Pumped: Gallons
3. Component: F] Cesspool(s) Septic Tank ❑ Tight Tank El Grease Trap
Other(describe):
4. Effluent Tee Filter present? 0 Yes F?/No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
(11
0 ", IJ
6. System iumped BY: 7
Name ---------4------ Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 SoMill St.,Bradford,IVIA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11112 System Pumping Record-Page 1 of 1