HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 926 FOREST STREET 6/4/2025 dvn of North Andover
Commonwealth of Massachusetts
x w City/Town of No.Andover JUN 4 202
System Pumping Record
` Form 4 cite 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 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 Address
cursor-do not
use the return
key. CityfTown State Zip Code
rib 2. System Owner:
,
Name
Address(if different from location)
No Andover MA
City/Town State Z-i p Code
Telephone Nupi be-r
B. Pumping Record
1. Date of Pumping --- 2. Quantity Pumped: --------.__--
p g Date - tY p Gall-ns
3. Component: [ Cesspool(s) ptic Tank [ _[ Tight Tank [ - Grease Trap
I Other(describe): —........ .___ __-- - __ ---_ --
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? j Yes _[ No
5 Observed condition of component pumped:
L ? ......._.. . _._ _... ._ -- ---------- --- __—_.
& Syste mpe By:
------
Name Vehicle License.Number
Stewart's Septic 53 So Kimball St Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
--......_.- ----__ -. ---._.. -----------
-----— _..... _ ----
Signature of Hauler Date-
-------- ._.—._._ ------------------ --..e-c-- _. ._.....---
-------
Signature of Receiving Facility(or attach facility receipt) Date---
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