HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 39 DEER MEADOW ROAD 4/2/2025 Town Of North Andover
Commonwealth of Massachusetts
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- City/Town of No Andover MAY
} System Pumping Record2
Form 4 Depar
nt
DEP has provided this form for use by local Boards of Health. Other forms may be used, but 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 CMR 15.351,
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, ✓'� r
use only the tab _ 4 --
key to move your Address
cursor-do not
usethe return : ---_............._-----__._..._.._.._.___........_ —_._._.._.. -----. —----�....__.._.. --- _.._.e..-----------............_..._...
key. City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
No Andover MA
City/Town --_ _ - State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ID - 2. Quantity Pumped: Gauons
3. Component: [ � Cesspoal(s) [ f Septic Tank [_.� Tight Tank ❑ Grease Trap
❑ Other(describe): - - - —
4. Effluent Tee Filter present? [:] Yes [_ No If yes, was it cleaned? (_] Yes E] No
5. Observed condition of component pumped:
6. System Pu ed B :
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 Sore
adford
at Date
Si nature of ReceAvin Facilit or attach facilit recei t Date
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