HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 112 TUCKER FARM ROAD 10/6/2025 Commonwealth of Massachusetts Town of lvofth AndoVer
City/Town of kx> CkA 9-r
System Pumping Record OCT 6 2025
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be uag',.bxhmt
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 I I A 7 cLc_V_or Fc4y m
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
2. System Owner:
Name-p-P-11
reoxn
Address(if different from location)
State Zip Code
Telephone Numbe
B. Pumping Record
1. Date of Pumping 5%te y 2 Pum Quantitped:
Gallons
0'
3. Component: Cesspool(s) I
L Septic Tank Tight Tank L_J Grease Trap
Other(describe):
4, Effluent Tee Filter present? ["I Yes _J No If yes, was it cleaned? Yes No
5. Observed condition of compone t pumped:
6. Syst P Aud By:
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
T Location where contents were disposed:
20 SoMill St.,Bradford,MA
Signature of Hooker Date
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