HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 105 SULLIVAN STREET 7/24/2025 1 own of Noah Andover
Commonwealth of Massachusetts
rt City/Town of No.Andover AUG z 2025
Y
System Pumping Record �. al
,f Form 4 '9P13rh
ent
DEP has provided this farm 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 farm, 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
riling 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
reb
2. System Owner:
----- -
Marne -- -- __
rendn
Address(if different from location)
No.Andover MA
City/Town State Zip Code
rbpr Telp hone Nu
B. Pumping Record
1. Date of Pumping ----- ------- 2. Quantity Pumped:
p g Date G ons ----- ._- -- .
3. Component: , Cesspool(s) 16-Septic Tank I Tight Tank ) Grease Trap
Other(describe): __-- .__........................._..__._.,,
4. Effluent Tee Filter present? Yes ] No If yes, was it cleaned? s [ ] No
5. Observed conditia of component pumped:
` .
up '6. yste m d By
Name Vehicle License Number
Stewart s Septic 58_Sa 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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