HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 252 BOXFORD STREET 7/30/2025 4 Commonwealth of Massachusetts T®wn of North Andover
r _ � City/Town of No.Andover AUG 1 1 2,025
w System Pumping Record
A
Form 4 Health 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 CMR 15,351,
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 0
use only the tab
key to move your Address
cursor-do not
use the return _..._................................ .._..---..------__ _.
key. City/Town State Zip Code
2. System Owner:
VQ
Name _.--------------. __.._
retran
Ad—dr-e---ss(if diff_. rent e.. _..._from_...l..o.....catio n}............-------- ---
No.Andover MA
Cty/Town State Zip Code
Telephone Number
B. Pumping Record
tt _ . � ._ ...._...
1. Date of Pumping .
.- _...::..._...._ � _...__-_ 2. Quantity Pumped: Gall n
3. Component: [ _) Cesspool(s) Septic Tank [ Tight Tank 1---1 Grease Trap
i _I Other(describe): __._._.....----------- - _ _ _._..--------------- _. ._.
4. Effluent Tee Filter present? 1 Yes < No If yes, was it cleaned? 1 Yes ] No
5. Observed condition of component pumped:
6. ."SyItem Pumped By
Name Vehicle License Number
Stewart's Septic 58 Sa Kimball St ,_Bradford,MA
Company
7. Location where contents were disposed:
20 rd,MA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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