HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 366 FOREST STREET 8/11/2025 =•v'L"lindOVer
{ . Commonwealth of Massachusetts IIG 1202,5
w City/Town of No.Andover
wn System Pumping Record ep
- Form 4
DEP has provided this, form for use by local Boards of Health. Other forms may be used, but the
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 ('MR 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
r 2. System Owner: h I .... ............................Name
ranan
Address(if different from location)
No.Andover MA
�_._.... __ ------- -- - __. .. _ .........
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Da - =- - Quantity Pumped: ---- - -....................................__.
Gallons
3. Component: [ .} Cesspool(s) Septic Tank j Tight Tank _.] Grease Trap
[ Other(describe): - --- ---
4. Effluent Tee Filter present? Yes - No If yes, was it cleaned? [ Yes ) No
5. Observed condition of component pumped:
............._ _.-- __.._._.._ .. _ _ _._-___ ------------- .___-__
6. Syste um ed B
Name Vehicle License Number
Stew 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
_.._ __. ___ --- ------ -- _...- _ _.____
Si_._gnature of Receiving Facility(or attach facility receipt) Date
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