HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1030 JOHNSON STREET 2/13/2025 Town of North Andover
Commonwealth of Massachusetts MAR - 4 2025
City/Town of No
mith Department
System Pumpi ecor o
ng Rd H
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
key. City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
the t�. MA Zip—
City/Town State Code
B. Pumping Record
IT
1. Date of Pumping 2. Quantity Pumped: T C)o
Date' 4 Gallons
1 Component: Cesspool(s) Septic Tank F� Grease Trap
I EI Tight Tank
❑
Other(describe):
4. Effluent Tee Filter present? E-1 Yes 1/1 No If yes, was it cleaned? El Yes Ej No
5. Observed condition of component pumped:
6. Sys ern Pumped By:
I 0"s L)in
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. ,Bradford,MA
Company
7, Location where contents were disposed:
20 SoWill St.,Bradford,MA
/M 0 yl�tf'c
Signature of Hauler Date
§141nit—ur-6--of Receiving—Facility(6-r at—tach—fa-ci-li-t-y-re—c--e-ip-t) Date
t5forn-4.doc-11112 System Pumping Record<Page 1 of 1