HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 121 FARNUM STREET 8/7/2025 ti Commonwealth of Massachusetts
City/Town of „No.Andover
w° System Pumping (Record
-- a 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, 4)1
use only the tab
key to move your Address
cursor-do not
use the return - --__ ._.. - ._ _ -------- ------ ----------�_..
key City/Town State Zip Code
2. System Owner.
T" 6vn of Nati Andover
red
Name T 2025
remm
Address(f different from location)
No Andover __..._.__. _ MA �.� __- atr�,� -----._--
City/Town State Zip Code
Telephone Nurber
B. Pumping Record ^y
1. Date of Pumping ba�tee 2. Quantity Pumped:
Gallons
3. Component: f Cesspool(s) Septic Tank Tight Tank Grease Trap
Other(describe): —
4. Effluent Tee Filter, present? Yes ] No If yes, was it cleaned?) 'Yes j No
5. Observed condition of component pumped:
6. System Pumped By:
Name Vehicie License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7, Location where contents were disposed:
20 So.Mi St.,Bradford,MA
o Signature auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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