HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 260 SUMMER STREET 6/4/2025 `own ° hA
Commonwealth of Massachusetts of dov��.
w City/Town of No.Andover
a n System Pumping Record JUN 4 2025
fForm 4
DEP has provided this form for use by local Boards of Health, Other forms may 6
information must be substantially the same as that provided here. Before using this form, chec with your
local Board of Health to determine the form they use. The System Puniping 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, r
use only the tab
�
Y Y
ke to move our Address
cursor-do not
use the return ---— -------- _.. -_ -- -------
key. City/Town State Zip Code
2. System Owner: ,
_....... _
Name _ ----
/BhX1I
Address(if different from location)
No.Andover MA
- — ___ - ---- --. -
City/Town State Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping 2. Quantity p Pum ed:
Date U"� Ions
3. Component: i _( Cesspool(s) Septic Tank j .I 'Tight Tank l ; Grease Trap
It _ Other(describe): _. _._.....__ _._. __--
4. Effluent Tee Filter present? _� Yes o If yes, was it cleaned? Yes [ l No
5. Observed condition of component pumped;.
fl
Zymp .. ,6. Pu ed ..."w � _.... �-
VehicleL'rderfse Number
Stewart s Septic 58 So Kimball St. , Bradford,_MA
Company
7. Location where contents were disposed:
20 So.Mill St. ford,MA
Signature af^ t -.:.g der ,,, Gate
Signature of Receiving Facility(or attach facility receipt) date
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