HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1 FOREST STREET 5/1/2025 r.
Commonwealth of Massachusetts TO wn or North
City/Town of No.Andover Andover
System Pumping Record
'ry�,qq Form 4 JUN 4 2025
DEP has provided this form for use by local Boards of Health. Other for ed, but the
information must be substantially the same as that provided here. Before ut4 IB � our
local Board of Health to determine the form they use. The System Pumping Record must be submitf' 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
;' - .. �-
key to move your Address ------_._._.......
cursor-do not
use the return —.-...-................ -_.-..-
key City/Town State Zip Code
��n
2. System Owner:
_ --- _ - - -
-- ------ _-----_..._ --- ----- ---- --- -- __...
Address(if different from location)
No.Andover MA
_... - -------- _ __.___. _____ - - - -- — - --._._.... ..... . ...._..-...........
----
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. QuantityPumped: __...__.___....._.._.
Date p Zallons
3. Component: I Cesspool(s) �' Septic Tank I I Tight Tank [ _] Grease Trap
I Other(describe): - --- - - -
4. Effluent Tee Filter present? j Yes j No If yes, was it cleaned? [ _ Yes No
5. Observed condition of component pumped:
6. yste _ Pump d ............. �..__.
...................-N --- ----------- ---__--- .............. ............ ............
ame Vehicle License Number
Stewart s Septic 53 So Kimball St. Bradford MA
..._... __.._.._ - -. - --
Company
7. Location where contents were disposed:
20 So.Mill . Bradford,
— --- __.. .. .._...
nature u er Date
TO
................-.............-. ._.....----
Signature of Receiving Facility(or attach facility receipt) Date
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