HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 380 BOXFORD STREET 7/17/2025 Commonwealth of Massachusetts down of North AndOV
City/Town of No.Andover �
w System Pumping Record AUG 112025
,w
Form 4
DEP has provided this form for use by local Boards of Health. Other lQ the
information must be substantially the same as that provided here. Before using this r th 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, a 1 ��" o ! G!1� ( f
use only the tab l !! C-' I
_ __ w.
key to move your Address
cursor-do not
use the return .......... ...
key. City/Town State Zip Code
2. System Owner:
_.._.._........ ._.. w�l t
...... _ ___-----
rattrn
— —---__._......-
Address(if different from location)
No.Andover MA
City/Tawn State Zip Cade
Telephone Plumber
B. Pumping Record
1. Date of Pumping gate --- 2. Quantity Pumped --._._. _ - --_... ... _ .. ................
Gallons
3. Component: ( ) Cesspool(s) k eptic Tank Tight Tank Grease Trap
Other(describe); - --- -----_ _. -.
4. Effluent Tee Filter present? Yes a If yes, was it cleaned? Yes i No
5. Observed condition of compo nt pumped:
& System P p Y
__.—___ _._.. .. -. .__..._.. .. ............. .. . ......._.
Name vehicle License Number
Stewart s Septic 5 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So MITI St.,Bradford,MA
__...,.._......_._.... . . - -- ._.__... . . ........... _-..----- .
_._.........__......._._..___........_......__..._.._......._.___.------------__.-...._.........._._._..._._. -_.. —--------
__.._._.____...._.._.............__._...____.___�--
Signature of Hauler Date
---- --- --.receipt.
Signature o f f Receiving Facility(or attach facility ) Date
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