HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 53 WELLINGTON WAY 5/1/2025 Commonwealth of Massachusetts U1 Ivorth Andover
City/Town of No.Andover JUN 4 2025
System Pumping Record
....... Form 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 __Z6.44
key to move your Address
cursor-do not
use the return --------------------------
key. City/Town State Zip Code
VQ 2. System Owner:
Name
Address(if different from location)
No.Andover MA
City/Town State Zip Code
...........
Telephone Number
B. Pumping Record b"5-//1,2 157�_
1. Date of Pumping atEr� 2. Quantity Pumped: Gallons
& 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. Systx��r�'
Nary(e Vehicle License Number
Stewart'sSeptic 58 So Kimball St._ Bradford_MA
Company
7. Location where contents were disposed:
20 So.Mill St., ordIVIA
Sig wgfgre of FUidret- Date
-_ - - ---- -_ -_ --- --------
Signature of Receiving Facility(or attach facility receipt) Date
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