HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 490 WINTER STREET 5/7/2025 TOVIn Of
Andover
nweaIth f Massachusetts
w City/Town of No.Andover JUN
System Pumping Record
Form 4 ,
br �
DEP has provided this form for use by local Boards of Health. Other forms may beiS"s ,
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,
use only the tab _..__......._......................................-----------
key to move your Addresscursor--do not
use the return _._.._. ------.
key.
City/Town State Zip Code
2. System Owner:
rx6
, P
Name - - --
rxnxn
Address(if different from location)
No..Andover MA
City/Town State Zip Code
Telephone Nurrrber
B. Pumping Record
1. Date of Pumping - ------ 2. Quantity Pumped: Gallons
3. Component: Cesspool(s) Septic Tank _� Tight Tank 1 Grease Trap
l � Other(describe): - .. _..
4. Effluent Tee Filter present? 1 .1 Yes ; No If yes, was it cleaned? _-f Yes No
5. Observed condition of component pumped:
6, Pumped By:
— ...._. ......._._........ --------
Na e 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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