HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 54 LONG PASTURE ROAD 6/5/2025 Commonwealth of Massachusetts
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Of City/Town of No.Andover /
w° System Pumping Record or �A��ov
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Farm 4
DEP has provided this form for use by local Boards of Health. Other fqb is be used, but the
information must be substantially the same as that provided here. Before L At% rm, check with your
local Board of Health to determine the form they use. The System Pumping Record ubmitted to
the local Board of Health or other approving authority within 14 days from the pumping date i /7t
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location
on the computer,
use only the tab _ r
Y move Y
key to our Address _.. -
cursor-do not
use the return _
key. City/Town State Zip Code
2. System Owner:
a�
f9tl67t
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
._.............
Da j . y Pum ed:
Gallons
3. Component: ; Cesspool(s) Septic Tank Tight Tank �1 Grease Trap
Other(describe): -- - . . -- .. -------- _
4. Effluent Tee Filter present? Yes ; No If yes, was it cleaned? Yes i No
5. Observed condition of component pumped:
DAN
e � w
6. §y
Pumped By
-- ry - _-___......... - _...._ . .... ...
Name Vehicle License Number
Stewart s Septic 58 So Kimball St Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,BrEdford,MA
_ - _._
_. .. .... - -- .......
Signature auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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