HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 350 HOLT ROAD 5/7/2025 10M of North Andover
Commonwealth of Massachusetts
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City/Town of No.Andover `� � 2025
W° System Pumping Record
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- Form 4 a .
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1. .} 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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, ,
use only the tab 4 ._. . . _.... --__. ----
key to move your Address
cursor-do not
use the return - - -- - --- - - - - - -- --------
key City/Town State Zip Code
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2. System Owner:
Name -. _...
✓enan
Address(if different from location)
No.Andover MA
City/Town State Zip Code
------------..------._......------- -----
Telephone Number
B. Dumping Record
1. Date of Pumping bate 2. Quantity Pumped:
3. Component: ] Cesspool(s) Septic Tank [ j Tight Tank � ) Grease Trap
_] Other(describe): - —
4. Effluent Tee Filter, present? Yes No If yes, was it cleaned? -_, es _; No
5. Observed co tion of component pumped:
6 System Pumped lay:
Name Vehicle License Number
StewarYs Septic 5 . So Kimball St. , Bradford,MA
Company
- - ---_.----------------
7. Location where contents were disposed:
20 S St.,Bradford,MA
Signature of Hauler Date
----------i---.---------— ------------------------- -
Signature of Receiving Facility(or attach facility receipt) Date
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