HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 BARCO LANE 7/31/2025 Commonwealth of Massachusetts Town ofNOrthAndo
W City/Town of No.Andover Vet"
w System Pumping Record Form 4 1025
e
DEP has provided this form for use by local Boards of Health. Other NiSeftty ed, but the
information must be substantially the same as that provided here. Before using f�i ith your
local Board of Health to determine the form they use. The System Pumping Record must be su fitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab -- ---_. - --- - C :.: .-_..__ .......... ......_ . ........ ---------- ------
key to move your Address
cursor-do not
use the return ---- ---- --- -- -- - ----- - - ---- ---_-..
key. City/Town State Zip Code
2. System Owner.
Name
tehan
Address(if different Pram location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
6x)
1. Date of Pumping Date 2. Quantity Pum ed: dall an-s -- - --
3. Component: ) Cesspool(s) Septic Tank [ J Tight Tank [-� Grease Trap
Other(describe); ___ __-----.---
4. Effluent Tee Filter present? [ 1 YesX No If yes, was it cleaned? 1 Yes _ No
5. Observed condition of component pumped:
6. System P mped By
- - -..__ _----- — - - --
Name "m "' 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 fa Hauler date
------ --------------——
Signature of Receiving Facility(or attach facility receipt) Date
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