HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 266 LACY STREET 7/15/2025 Commonwealth of Massachusetts Town Of North Andover
C ity/Town of K�o- Prn&cu Q-r A UG 112025
System Pumping Record
Form 4 Heafth Department
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 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
Q2. System Owner:
Name
imam
Address--(if didement from location)--------
........................... ...............................
City/Town State Zip Code
Tefeoone--N—urn-b-e-r
B. Pumping Record
1. Date of Pumping iantity Pumped: A iorc-�
Daty Gallons
3. Component: Cesspool(s) Septic Tank Tight Tank Grease Trap
'14
Other(describe): -------
4. Effluent Tee Filter present? [- I Ye No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
6 S d By:
S�mpe
� Pt'ujc)
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,IVIA
Company
7. Location where contents were disposed:
20 SoMill St.,Bradford,MA
C-
Signature of H ai-U-Ier Date
Signature of Wig-Facility(or attach facility receipt) Date
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