HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 11 BRADFORD STREET 1/24/2025 Commonwealth of Massachusetts
City/Town of No Andover
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
key to move your Address
cursor-do not
use the return State ----------- Zip Code.__-..__._______.-..____.
key. 2. System Owner: Of North Andover
-Name ---------------------------
32025
Address—(if dFfferenfTr6mi`ocation)
No Andover MA D--
City/Town State KHwmen
T-el—ep-ho-re—Number
B. Pumping Record
1. Date of Pumping De 2. Quantity Pumped: 40e
3, Component: Cesspool(s) A-Septic Tank F] Tight Tank [—I Grease Trap
E Other(describe):
4. Effluent Tee Filter present? D Yes Po If yes,was it cleaned? ❑ Yes ❑ No
5. C7bs ed condition of component pumped:
6. Sy Pum ed By'
o, �L Na me Vehicle License
Number
Stewart's Se Bradford MA
St. n==-:
Company
7. Location where contents were disposed:
20 SoMill §t.,BrqdfordMA
Signature of Hauler Date
Sig"6it-64 of Ai6ei—ving ri&fity(®r afti6ii-facility re661pf)--- Date
-
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