HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 1077 OSGOOD STREET 8/19/2025 Commonwealth of Massachusetts
x City/Town of No.Andover
wry System Pumping Record
�r`/\ 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 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location
on the computer, _
use only the tab ll '
--- - — _
key to move your Address ---___
cursor-do not ,°
use the return �� P �� - - ----- �'��
City/Town Late Zip Code
key
tab
2. System Owner.
- Name
. Town-of rtFi__ ndavr
FE2&71
Address(if different from location)
No.Andover MA
City/Town State ip ode
Telephoneff umbef r e„+
rwft
B. Pumping Record
%-,/, /
C Gallons-- ..._. -- -
1. Date of Pumping Date ----- 2. Quantity Pumped: ---
3. Component: j Cesspool(s) Septic Tank J Tight Tank ` hGrease Trap
Other(describe): -- --- --..__ - - -- ------------------ _------- --- ------- --------------
4. Effluent Tee Filter present? I } Yes K No If yes, was it cleaned? _; Yes ( -� No
5. Observed condition of component pump
ed:
--------------------._.._ ---._.._.--- ---
5. S stem Pumped By:
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
-- - . .... 1 - --- --
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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