HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1551 OSGOOD STREET 4/25/2025 Commonwealth of Massachusetts Town of °fth Andover
City/Town of No.Andover
- MAY 5 2025
System Pumping Record
Form 4 ,
qrtment
DEP has provided this form for use by local Boards of Health. Other forms may be used, ut 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 CMR 15.351.
A. Facility Information
Important:When
fining out farms 1. System Location: -�.
on the computer, j
use only the tab - — q -. .... . --
key to move your Address
cursor-do not
use the return _ _ __._._ ---------_-- ._____.__.._...... _..
key. City/Town State Zip Code
2. System Owner:
rib ,
L
Name .- _ _. _._ ........_
return
Address(if different from location)
No.Andover MA
City/Town State Zip Cade
Telephone Number
B. Pumping Record
1. Date of Pumping D _.° - --_....... 2. Quantity Pumped: Gaq11P
3. Component: Cesspool(s) I SSeptic Tank , Tight Tank I _ Grease Trap
.. Other(describe): _.--------
4. Effluent Tee Filter present? [ ] Yes ( -�No If yes, was it cleaned? Yes ,_] No
5. Observed condition of component pumped
& System P m d By
ck—
...........
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
e er Date
Signature of Receiving Facility(,or attach facility receipt) date
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