HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 142 BERRY STREET 8/13/2025 Commonwealth of Massachusetts
City/Town of No.Andover
System Pumping Record
Form 4
ChM
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 1'o 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 — --- ------._....-¢� --- ='_ - ,.�, { .._
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
&� 2. System Owner: Town of Nofth Andover
........................................... -------SEP
Name
return
- -4f-different fr om_Iocati_on) ____ ----------------------
Address --No.Andover MA
1�,l Departmont
City/Town State Zio Code--
f4ephori-e-Number
n-bef
B. Pumping Record
1. Date of Pumping Date- 2. Quantity Pumped:
Gallons
3. Component: F Cesspool(s) eptic Tank Tight Tank 1-
_] Grease Trap
Other(describe): ...........
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? )11'fyes No
5. Observed condition of component pumped:
6. m Pumped By:
Na e Vehicle License Number
Stewarf s Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 SoMill St.,Bradford,MA_ ----------------------
ell\
Si nature of Hauler -mom"
—Date
Signature-of-Receiving-Facility(or attach facility receipt) Date
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