HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 549 WINTER STREET 5/5/2025 Commonwealth of Massachusetts 4ndQVer
City/Town of No.Andover
System Pumping Record JUIV2o25
r /V� Form 4
COSth
DEP has provided this form for use by local Boards of Health. Other forms may be used, b ften '
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 approviing 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
/p
4-- - --_. !_ _
key to move your Address __._..-.--
cursor-do not
use the return ,___.__. ..................
key.
City/Town State Zip Code '---- — —
2. System Owner:
rob �✓
-- — _
Name _........._..._.._.._._----
rnnsn
Address(if different from location)
No Andover MA
City/Tawn State Zip Cade
Telephone Number
B. Pumping Record
-- _
1. Date of Pumping Date w, p--- 2. QuantityPum ed: .........._.._._...._......_..
G Iions
3. Component: Cesspool(s) Septic Tank ] Tight Tank f Grease Trap
L _I Other(describe): __._. 1 -- -_ -----------------._._.
4. Effluent Tee Filter present? Yes No If yes, was if cleaned? j ] Yes J _] No
5. Observed condition of component pumped:
6. S em Pumed By
N me Vehicle License Number
Stewart,s Septic 58 So Kimball .....................
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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