HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 161 BRIDGES LANE 5/7/2025 ve
Commonwealth of Massachusetts ` a� n of��a�h Anda r
W City/Town of No.Andover JUN4 2025
rn System Pumping Record
a 0 :
Farm 4 " t- �.�p
c
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 farm 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 (,MR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location
on the computer, / .
use only the tab . _._.._ _..- µ.
key to move your Address
cursor-do not
use the return -_----------- - _ _..-- --- ___.
key. City/Town State Zip Cade
VQ 2. System Owner:
Name
�emm
Address(if different from location)
No.Andover MA
Cityd own State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping fit _._.._......_.-- ---.._____--- 2. Quantity Pumped: Ga Ions
3. Component: ( Cesspool(s) Septic Tank { .] Tight Tank Grease Trap
Other(describe): ----- __ ---
4. Effluent Tee Filter present? Ye _ No If yes, was it cleaned? Yes _] No
5. Observed condition of component
6. Sly, mped By:
Name' -_ _. _..__..._.—_� _....__..._._....
Vehicle License Number
Stewart's Septic fib So Kimball St._Bradford,MA
---_..._......_....
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
_ ..._.__ ._,..__. -_ _
„a
— — —. --_.._.._ — ----
Signature of Hauler (Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record-Page 1 of 1