HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 288 FOSTER STREET 8/27/2025 Commonwealth of Massachusetts Town of Norlh Andover
City/Town of No.Andover
- System Pumping Record
. . ... a Form 4 SEP 2025
/1 Y DEP has provided this form for use by local Boards of Health. Other fI s m b sed, but the
information must be substantially the same as that provided here. Bei` h "' t 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. CityiTown State_..._. Zip Code
� 2. System Owner. b�
y
Name
iel+an
Address(if different from location)
No Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
/ _ fs "C
1. Date of Pumping _ .. 2. Quantity Pumped: -- --
Da Lallans
3. Component: Cesspool(s) 11�1 Septic Tank ( Tight Tank _] Grease Trap
Other(describe);
4. Effluent Tee Filter present's Yes No If yes, was it cleaned? ; Yes No
5. Observed condition of component pumped:
f
6.
System Pumped By:-1. fi , _ _ .. . - ---- - -
Name Vehicle License Number
Ste warYs Septic 58 So Kimball St Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
"•Srgrratcrre df tduler Date
Signature of Recei-vintl Facility(,or attach facility receipt) Date
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