HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 122 OLYMPIC LANE 6/19/2025 Commonwealth of Massachusetts TOVIn of 1Vort hAndover
1 W City/Town of No.Andover
y
System Pumping Record JUL 225
� Form 4
DEP has provided this form for use by lilcal Boardsof Health. Other forms may be use g9aq p1 ��
information must be substantially the same as that provided here. Be ore using this form, check witeh yttur
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 MR 15.351.
A. Facility Information �^
Important:When
filling out forms 1. System Location:;
on the computer,
use only the tab = C / J
key to move your Address __-- --
.------------__---
cursor-do not
use the return key. City/Town State Zip Code
2. System Owner:
Name __._..._- --- --- — --
renrn
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
Pumping Record
� - -- - -
1. Date of Pumping Date"" ( — - 2. Quantity Pumped:
ons
3. Component: ;J Cesspool(s) eptic Tank ] Tight Tank ; Grease Trap
Other(describe): -- ----- ---------
4. Effluent Tee Filter, present? -� Yes ( _ o If yes, was it cleaned? Yes I -f No
5. Observed(condition of component pumped:
6. Syst perk 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 of Hauler Date
----- — - ------- ------.._.. -------- ------- __—.— ----- ------ — --------
Signature of Receiving Facility(or attach facility receipt) date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1