HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 GRAY STREET 3/20/2025 Commonwealth of Massachusetts
u - w p City/Town of No Andover
^ System Pumping Record oaf
h
Form 4 (� V
er
DEP has provided this farm for use by local Boards of Health. Other farms may be use th
information must be substantially the same as that provided here. Before using this form, c ec ur
local Board of Health to determine the form they use. The System Pumping ord must be submitted to
the local Board of Health or other approving authority within 14 days from the d e in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location: zi
on the computer, j
use only the tab --
key to move your Address
cursor-do not
usethe return ....... -.......................-- --.__...__..._.......- --..._..__... - —....__..._..._._.. -- -.__._.................----....._._..._.._.._....
key. City/Town State Zip Code
2. System Owner:
Name
reran .-
Address(if different from location)
No Andover _ MA
City/Town State Zip Code
Telephone Number
B. Pumping
Record
� e '
1. Date of Pumping Da eQuantity Pumped: Gallons ---
3. Component: [-_.� Cesspaal(s) [ Septic Tank [__.-.� Tight Tank [__j Grease Trap
[__] Other(describe): — ...... -
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? [._] Yes [_] No
5. Observed condi 'on of com nent pumped:
6. System um ed By: .
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company _
7. Location where contents were disposed:
20 So.Mlll St.,Bradford,MA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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