HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 124 PENNI LANE 4/7/2025 Commonwealth of Massachusetts L1,Y11 Of North Andover
City/Town of No Andover
MAY 5 2025
System Pumping Record
Form 4
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DEP has provided this form for use by local Boards of Health. Other forms may be
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 State Zip Code
Z System Owner:
Name 1)
Address(if different from location)
No Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2, Quantity Pumped:
3. Component: Cesspool(s) Septic Tank Tight Tank Grease Trap
Other(describe): ......
4. Effluent Tee Filter present?
Yes;(LNO If yes, was it cleaned? Yes [.j No
5. Observedcondition f component pumped:
T component
& System P�
N .. Vehicle License Number
Stewart's Septic_58 So Kimball St._,_Bradford,MA
Company
7. Location where contents were disposed:
20 SoMill St.,Bradford,MA
Signature of Hauler Date
Signature of Facili
ty lity(or attach facility receipt) Date
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