HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 LIBERTY STREET 4/17/2025 Town of North Andover
,L\ Commonwealth of Massachusetts
City/Town of No Andover MAY 5 p025
System Pumping Record
Form Health Department
4
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 State Zip Code
2. System Owner:
Name
Address(if different from lo6ia—fion) —
No Andover MA Tip—Code
City/Town State
Telephone Number
B. Pumping Record 1121�
1 Date of Pumping Gallons
D 2. Quantity Pumped:
1 Component: El Cesspool(s) Grease Trap
Septic Tank Tight Tank
Other(describe): ...........
4. Effluent Tee Filter present? Yes>�No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
6. (§�Jm Pumped By:
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 hate
Ignature of Receiving Facility(or attach facility receipt) Date
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