HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 144 SULLIVAN STREET 8/11/2025 _ Commonwealth of Massachusetts .
;21 == w City/Town of �:�n c IN If ofth Andover
wry System Pumping Record
Form 4
AUG I
DEP has provided this form for use by local Boards of Health. Other f r s ma be used, but the
information must be substantially the same as that provided here. Be {r��jtt l ( h your
local Board of Health to determine the form they use. The System Pumping Record s 15 tted 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 Information
Important:When
filling out forms 1. System Location:
on the computer, \
use only the tab .. _ . .1.1.. .._-- —__-__.....___. _ _----_._ ._.....__ -.._._.--
key to move your Address ----_ _ _..__..._-
cursor-do not
use the return ----._____. .__......_. _. __._._.___-- -___--
key. City/Town State Zip Code
VQ 2. System Owner:
Name _.. _...�.........
,�ettan
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping [iate.-..---_-__ _----------- -- 2. Quantity Pumped: Dai s -- .:°. - .............
3. Component: ] Cesspool(s) ISeptic Tank [ Tight Tank _.j 'Grease Trap
Other(describe):
4. Effluent Tee Filter present? �� Yes - o If yes, was it cleaned? I Yes ( .� No
5. Observed condition of component pumped:
6. Syste mpe 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 Mauler Date
-------------
Signature of Receiving Facility(or attach facility receipt) Date
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