HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 25 ABBOTT STREET 8/6/2025 Commonwealth of Massachusetts
City/Town of Qo
System Pumping Record
Form 4
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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab ab
key to move your Address
cursor-do not MA
use the return
key. City/Town State Zip Code
2. System Owner: Town of NoO Andover
Name
Address(if different from location)
City/Town State
Heal'Li.
Telephone Number
B. in Record
1. Date of Pumping A� 2. Quantity Pumped:
Date / Gallons
3. Component: 7 Cesspool(s) _ 'Septic Tank 7 Tight Tank ❑ Grease Trap
7 Other (describe):
4. Effluent Tee Filter present? 7 Yes .[ No If yes, was it cleaned? 7 Yes 7 No
5. Observed condition of component pumped:
01 -no(�� All of this estimated
information is non-binding, valid o—ql at the time of pumping. Not responsible beyond the date above.
6. System Pumped By:
Name Vehicle License Number
AS Development Corp. d/b/a Stewart's Septic
Service
7. Location where contents were disposed:
Stewart's Receiving_Facility, 20 So. Mill St., Bradford, MA 01835
See above
-Signature— Date
See above
Signature of Receiving Facility(or attach facility receipt) Date
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