HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 65 STANTON WAY 4/21/2025 Commonwealth of Massachusetts "V'r` `` 1�40 Andover
µ w City/Town of No.Andover
System Pumping Record MAY 5 2025
>, q Form 4
r
DEP has provided this form for use by local Boards of Health. Other forms I a ()p he
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 _._ _...._—.. .. ._..._.__._......�. .__... .. f ..___. :` Z . ..
key to move your Address __... __ _.... . .---...._._—.... .__.-_--
cursor-do not
use the return ---._ ... .._ ___..- ---__.__--
key. City/Town State Zip Code
VQ 2. System Owner:
............ ---. . - ......_ ._.._....— ...._.__
Name
fR(lRTI
Address(if different Pram location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
f` ___.. 2 Quantity Pumped:
Da Gallons
3. Component: Cesspool(s) Septic Tank ] Tight Tank Grease Trap
l Other(describe): -- .... ._... ...__ .. _.__.... _..__...
4. Effluent Tee Filter present? j Yes P" No If yes, was it cleaned? ( Yes _--] No
5. Observed condition of component pumped:
s
6. ystPumped By:
....._ .... -__ — ._..__.. -- — --..._ .— --
Name Vehicle License Number
Number
Stewart s Septic 58 So Kimball St Bradford,MA
Company
7. Location where r;ontents were disposed:
20 S. ._.._
D_ e
-_ V Signature of Hauler at
Signature of Receiving Facility(or attach facility receipt) Date
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