HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 31 STONECLEAVE ROAD 4/10/2025 Town of North Andover
�L\ Commonwealth of Massachusetts
City/Town of No Andover MAY 5 2025
System Pumping Record
Form 4 c - Department
HA�th
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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 CIVIR 15.351.
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
key. City/Town —-------- ipco6e-
2. System Owner:
Address(if different from location)
No Andover MA
CityfTown State Zip Code
T6iephone-
B. Pumping Record
1. Date of Pumping rat 6 qh(" 2. Quantity Pumped: /T-00'
I Gallons
3. Component: El Cesspool(s) �Septic Tank Tight Tank
E, Grease Trap
Other(describe):
4. Effluent Tee Filter present? El Yes No If yes,was it cleaned? F. Yes EJ No
5. Observed condition qf component pumped:
6. System Pumped By:
Hama Vehicla�License er
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 SoMill St.,13radford,1VIA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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