HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 20 CHRISTIAN WAY 6/4/2025 Commonwealth of Massachusetts Ado er
City/Town of No.Andover JUN K
w° System Pumping Record
Form 4 d
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 _ J
key to move your Address - - .—._.___._......._.
cursor-do not
use the return
key. City/Town State Zip Cade
2. System Owner:
,Q
Name
,enrn
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record ) 00
1. Date of Pumping aat=e y- Quantity Pumped: -_ -- - -
Galians
3. Component: ( Cesspool(s) _.I Septic Tank Tight Tank _) Grease Trap
Other(describe): _....___._._—__---_.___.._..... __-- __.__ ..
4. Effluent Tee Filter present? J Yes lNo If yes, was it cleaned? Yes _� No
5. Observed condition of compond t pumped:
& System Pum d Ty:
Name .. ._. ..... .��__ Vehicle License Nun... --._.._....___-
mber
Stewart s Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
_....._---- _......-..._.. - -------
Signature of Hauler Date
Signature of Receiving facility(or attach facility receipt) Date
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