HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 107 ROCKY BROOK ROAD 8/7/2025 L Commonwealth of Massachusetts
City/Town of .No.Andover
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 e"6., --/
------------- .......
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
2. System Owner:
VQ Town of North Andover
Na-me
------------- ....... ..........................
Address(if different fiorn location)
No.Andover MA
-------------
City/Town State : : Z" Code
i- 31& I a R m e n t
telephone-N-u-m-ber
B. Pumping Record
1. Date of Pumping Date y....................... 2. Quantit Pump ed:
Gallons
3. Component: Cesspool(s) Septic Tank ILJ Tight Tank J_j Grease Trap
[_ ] Other(describe): ----------------------------------------------------
4. Effluent Tee Filter present? Yes J-W-0111",` If yes, was it cleaned? Yes No
5. Observed condition of componel�pumped:
6. System P pe ,B
B 77
--------------------
Name 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 of f Hauler D-ate
Signature of Receiving Facility(or attach facility receipt) Date
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