HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 TIFFANY LANE 6/4/2025 Commonwealth of Massachusetts row/? °f//° `
M w� City/Town of No.Andover h,q�4'®Ver
System Pumping Record �UL
Form 4 Zp
DEP has provided this form for use by local Boards of Health. Other Nor - used, but the
information must be substantially the same as that provided here. Before using gA eck with your
local Board of Health 'o determine the form they use. The System Pumping Record muus eVWitted to
the local Board of Health or other approving authority within 14 days from the pumping date In
accordance with 310 GMR 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. City/Town State Zip Code
ratr 2. System Owner: _
,
Name ---- --- -------
rensn
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping date --- --- ----- 2. Quantity Pumped:
Gallons
3. Component: 1
1 ] Cesspool(s) ;�Septic Tank Tight Tank 1 Grease Trap
- 1 Other(describe): - -
4. Effluent Tee Filter present? 1 , Yes. No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
- --- -------...-— - - -., .......... -da TA —--- ---- — -
6. Sys, mped By:
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
Signature tl °+hauler Date
- r--f--.__------ —------.__..__.----_._..---- ------- --------- -- -- ----- ---
Signature of Receiving Facility(or attach facility receipt) Date
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