HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 62 WILLOW RIDGE ROAD 5/5/2025 Commonwealth of Massachusetts ndaver
City/Town of No Andover
- W System Pumping Record MAY 202
,.
Form 4
DEP has provided this form for use by local hoards of Health. Otherfiorms m
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, .
use only the tab I• �^'�"" � �(/°�' r
key to move your Addr ss
cursor-do not �
use the return a ".._.._.._.._ --- -......_. .._.__.....-_- ..__... .._ .....� .... ..... _ __ --..... ..........
key. City/Town State Zip Code
2. System Owner:
Name
rerun
Address(if different from location) _
No Andover _ _MA
City/Town State Zip Code
Telephone Number — _-�-
B. Pumping Record
1. Date of Pumping ---- 2. Quantity um Gallon
Pumped: s -
Date uan p s
3. Component: Cesspool(s) eptic Tank E_] Tight Tank [.__] Grease Trap
Other(describe):
4. Effluent Tee Filter present? ] Yes No If yes, was it cleaned? [__] Yes � ] No
5. Observed condition of comp nent pumped: —�
6. System
Name -- --- Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA _.
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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