HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 82 BEAVER BROOK ROAD 4/3/2025 TAyn of/V6
,1\ Commonwealth of Massachusetts rth Andover
City/Town of No Andover
MAY
System Pumping Record 52025
Form 4
th D
"RAW
DEP has provided this form for use by local Boards of Health. Other forms may be use itment
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 16.351.
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 51t—iif
key. own— State Zip Code
Z System Owner:
VQ
Name
Addresi(if different from location)
No Andover MA
City/Town State Zip Code
Telephone Number
--'ff.Pu'rnptngAk61rd' V2-
1. Date of Pumping D t 2 Quantity Pumped:
--; . 41lons
3. Component: Cesspool(s) Septic Tank Tight Tank C Grease Trap
Other(describe):
4. Effluent Tee Filter present? El Yes V No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
6. syste P um ed B
Nam Vehicle License Number
Stewart's S epic 58 So Kimball§t , Br@�dfordIVIA
Company
7. Location where contents were disposed:
20 oMill gt.,Bradford,IVIA --
Signature of Hauler [late
Signature of Receiving Facility(or attach facility receipt) Date
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