HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 324 BERRY STREET 6/9/2025 ro Wn CfNoo�na
Commonwealth of Massachusetts Over
City/Town of No.Andover JUt 8
System Pumping Record 2025
Form 4 "ea'th Dep.71 c
DEP has provided this form for use by local Boards of Health. Other forms may be used, buff lt
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 CIVIR 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
2. System Owner:
Name- ---------------- ---------------- --------------- ------------
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone-Num----ber______
B. Pumping Record
1. Date of Pumping . Quantity Pumped:60- 2 Q tit P d ba_gins
3. Component: Cesspool(s) �eptic Tank Tight Tank [j Grease Trap
I � Other(describe): ---------------------------------------- ..........
4. Effluent Tee Filter present? [_ I Yes _I No If yes, was it cleaned? Yes No
5. Observed condition of component pumped'
6. Sy te P Na e Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St-jB'4�r Pd d_,
C_
------------
9i6ntuFe ofTauer
Signature f Receiving Facility(or attach facility receipt) Date
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