HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 40 PHEASANT BROOK ROAD 4/3/2025 Commonwealth of Massachusetts Town 0j -ijodh Midover
City/Town of No Andover
System Pumping Record mg 5 Z05
Form 4
DEP has provided this form for use by local Boards of Health. 0 er fo WAle
information must be substantially the same as that provided her . ISIPPIS Is , 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 17)
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return 6—tiiT—c�wn— State Zip Code
key,
2. System Owner:
Name
Address(if—different from—location)
No Andover MA 'Zip—Code --
City/Town State
— ng Record
-6. PUMpi
B. Pumping Record
2. Quantity Pumped: 15-a-D ,
1. Date of Pumping Da e ��allons
3. Component: F
Cesspool(s) Septic Tank F Tight Tank Grease Trap
Other(describe): ...............
4. Effluent Tee Filter present? j Yes _?`No If yes, was it cleaned? ❑ Yes No
5. Observed condition of component pumped:
6. qystq4 , ed By-
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Br��qfordIVIA
Company
7. Location where contents were disposed:
20 So.Mill St. Bradf MIA
aule Date
Signature of Receiving Facility(or attach facility receipt) Date
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