HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 8/8/2025 Commonwealth of Massachusetts
City/Town of No.Andover
System Pumping Record
Form 4
DEP has provided thiE.form for use by local Boards of Health. Other fcrms may be used, but the
information must be substantially the same as that provided here. Bef,,-)re 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
key to move your Address
cursor-do not
use the return ------------..........
key. City/Town State Zip Code
VQ 2. System Owner: Town of Wh Andover
Ad-d-rens—(if offerent-f-rc,)-m-—location) ---------
No.Andover MA
City/Town State-
b�trtme6t
Telephone_ Number_
B. Pumping Record
ll. Date of Pumping I Date- ----------------- 2. Quantity Pumped: Gallons
3. Component: Cesspool(s) tic Tank ; Grease Trap
I I Tight Tank
F] Other(describe)-. --—-------
4. Effluent Tee Filter present? Yes i No If yes, was it cleaned? Yes No
5. Observed condition of compo�nnt pumped:
6. Syster Pum e By:
Name' Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 SoMill St.,Bradford,MA
Signature of Hauler —Date
Signature of -R-e--c--e-i-v--iiig--Facility--(or-attach--fa--cil-i-t--y--r-e-c-e-ip--t-)--------- Date -----------
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