HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 88 ROCKY BROOK ROAD 7/16/2025 Commonwealth of Massachusetts Torun of North Andover
r City/Town of No.Andover
w° System Pumping Record AUG 2025
Form 4
811 1 De par �y �}
DEP has provided this form for use by local Boards of Health. Other farms may be used,'t3ut"tW
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 CMR 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
usethe return - .. - --. ------ __... ____ __...__.._.. .._..---- - __.._. ............._...__....-..._------
key. City/Town State Zip Cade
2. System Owner:
reb
Name __
ren�n
Address(if different from location)
NoAndover MA
_----- _._..__.. . _.___._. _.. ----- _._ ------ ----- -i- --......._...._-._...-_._._-.-_.-..._._..
City/Tawn State Zip Cade
Telephone mirnt r
B. Pumping Record
1. Date of Pumping r7ate - __._. 2, Quantity Pumped:
Gallons
3. Component: ] Cesspool(s) Septic Tank _�, Tight Tank _ Grease Trap
Other(describe): _.._..___.__. _......- _. ... _. _
4. Effluent Tee Filter present? Yes °1, No If yes, was it cleaned? Yes j _� No
5. ObPSe,
of mponent pumped
System6. e - .Nam VehicleLicense NumberSteSo 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
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