HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 871 FOREST STREET 7/21/2025 Commonwealth of Massachusetts Town of NoMAndover
7 City/Town of No.Andover
w° System Pumping Record AUG Z z 2D25
a�
Form 4
DEP has provided this form for use by local Boards of Health. Other f qqdi
information must be substantially the same as that provided here. Before using this farm, chec Lth 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
use only the tab
key to move your Address
cursor-do not
use the return —-- --- ---------------- -- -
key. City/Town State Zip Code
r� b,IW-17 a
2. System Owner:
-- ---
renmr
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone N�arnber
B. Pumping Record
1. Date of Pumping bate _..__...___._.... .__. 2. Quantity Pumped: Gallons - -----
3. Component: [ _] Cesspool(s) Septic Tank [ ] Tight Tank j Grease Trap
�..-.. Other (describe): -------- — - - -----
4. Effluent Tee Filter present? _1 Yes, No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
6. Syste ed 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 Hauler Date
---------- ----- ---..._.._ - - ----- —-- - --- _._...------ ------- ----------------
Signature of Receiving Faality(or attach facility receipt) Date
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