HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 110 FOREST STREET 5/6/2025 0" 'flVorth4nd0ver
Commonwealth of Massachusetts
City/Town of No Andover JUAI 4 2025
System Pumping Record
DePartrner)t
Form 4 Hc
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 fm 1. System Lo one coer,e only theb
key to move your Add ess
cursor-do not
use the return City/Town #ate -----._.._______
Zip-Code
key.
2. System Owner:
'5 C
Name
Address(if different from location)
No Andover MA
City/Town State Zip Code
Te ephone Number
B. Pumping Record
10c) 0
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: E] Cesspool(s) [Septic Tank Fj Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? 0 Yes /-- No If yes,was it cleaned? ❑ Yes ❑ No
5, Observed condition of component pumped:
9 00�_
6. System Pumped By:
---
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 SoMill St.,Bradford,MA
Signature of Hauler Date
Si nature of-Receiving Facility(or attach faci F1ti_r_eo61pi) Date
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