HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 514 WINTER STREET 5/8/2025 Town of North Andover
Commonwealth of Massachusetts
City/Town of No.Andover JUN 4 2025
System Pumping Record
Form 4 Department
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 forms 1. System Location:
on the computer, /7
use only the tab
....... ....... z7t!-
key to move your Address
cursor-do not
use the return
key. City/Town State Zip-do de
2. System Owner: /4z
VQ
reran
Address-(if-different' f r_otn1_o_c_a_t_ion)___
No.Andover MA
City/Town State Zip Code
tei—eph—one N___u_rnbe_r________
B. Pumping Record
1. Date of Pumping -bit e- Quantity Pumped: Gaflons
3. Component: LJ Cesspool(s) , Septic Tank 'Fight Tank [ j Grease Trap
Other(describe): ------------------------- ---------- --------
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? !Y Yes No
5. Observed condition of component pumped:
Do L)0............ ------------
6. Syst umped By-
---------------- ---------- ------
................ ---- --..........------
Nam 9 Vehicle License Number
Stewart's Se_pbc_58_So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 SoWill St.,Bradford,MA
i reo auler Date
................
Signature of Receiving Facility(or attach facility rece i�pt) Date
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