HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 66 BOXFORD STREET 5/5/2025 G� Commonwealth of Massachusetts Town of Nark Andover
City/Town of No.Andover 'UN
System Pumping Record 2025
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used bruften
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, P
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 _._ _.._....... ..__._.
lBR9J! Y_
Address(if different from lacatian)
No.Andover MA
- -- - - ----- — --- -- ... -------
City/Town State Zip Code
Telephone Number
B. Pumping Record �r
1. Date of Pumping JIIC�-'_. _...__._ 2. Quantity Pumped:
3. Component: I _� Cesspool(s) Septic Tank Tight Tank _� Grease Trap
Other(describe): ... ..._.._._ ._..._... ...
4. Effluent Tee Filter present? ( Yes No If yes, was it cleaned? Yes �i No
f
5. Observed condition of component pum e d __�nent �
_.._.. _._ ._. _... ..._a.
6. Syste _ _mpe By.
c_ _-_ _ _ = _ - --------- .......
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 Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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