HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 492 SALEM STREET 7/8/2025 Commonwealth of Massachusetts Town of No*gndaver
City/Town of No.Andover
JUL 8 202'5
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used,
he
information must be substantially the same as that provided here. Before using this farm, 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 informer ion
Important:When
filling out forms 1. System Location:
on the computer, t
use only the tab
key to move your Address - _ -- __.
cursor-do note ---
use the return P .... C --- -— . ..._. ------
key. City/Town State Zip Code
r�
2. System Owner:
Ca�e
Address(if different from location)
No.Andover MA
City/Town State Zip Code
felephone Nulmher
B. Pumping Record
1. Date of Pumping gate uantity Pumped:
Gallons
3. Component: ] Cesspool(s) Septic Tank ( Tight Tank Grease Trap
Other (describe): .... _
4. Effluent Tee Filter present? Yes ; No If yes, was it cleaned? l Yes ] No
5. Observed condition component pumped
.......... _ -------- --- _
6. System Pun d By.
Name Vehicle License Number
Stewart s Septic 58 Sa Kimball St. , Bradford MA
Company
7. Location where contents were disposed:
20 So Mill St.,Bradford,MA
Sig ................ ....._. .. _ --------- — __._ .. ._. . ... __- - --------
Signature of..Hauler date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1