HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 72 SUNSET ROCK ROAD 4/18/2025 �
c Commonwealth of Massachusetts 0W1 of NoA Andover
_ = City/Town of No.Andover
MAY 5 2025
System Pumping record
„ w Form 4
ec' `d� ED
DEP has provided this form for use by local Boards of Health. Other forms may bets t
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 Locatiom
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 .__....
_.
reran
-_.... ---,_....._ _ -.__._._
Address(if different from location)
No.Andover MA
City/Town State Zip Code
__..-p--h-o-n—e
Telephone Number
B. Pumping Record
1 1. Date of Pumping - m 2. Quantity Pumped: :_ _..._..-.._
Da e Gallons
3. Component: Cesspool(s) ,Septic Tank _� Tight Tank � Grease Trap
...-.......
Other(describe): _ —------ -
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes _ No
5. Observed condition of component pumped:
6. System P d By:
-..___.. -----
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 Hau Date
Signature of Receiving Facility(or attach facility receipt) Date
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