HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 122 FOREST STREET 10/6/2025 - Commonwealth of Massachusetts Town Of North n V
er
City/Town of No.Andover _
System Pumping Record OCT 2025
Form 4
DEP has provided this farm for use by local Boards of Health. Oth r " but the
information must be substantially the same as that provided here. Before using t ' rh$, (with your
local Board of Health 1:o 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 /,/ / }
key to move your Address _cursor--do not
use the return _......_ ----__-- --
key. City/Town State -- Zip Code __ _._ .-------
key.
2. System Owner: b
reb
"
Name _..-....
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date - 2. Quantity Purnped: ._...._.. _
Gallons
3. Component: _ Cesspool(s) Septic Tank Tight Tank �. Grease Trap
Other (describe): ._ -_._ - - __.._.. _.__.. .._...
4. Effluent Tee Filter present? 1 ] Yes � , No If yes, was it cleaned? f Yes ] No
5. Observed condition of component pumped:
....._......... - --_ ____.._._ .....
6. S Limped 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
Signature of Hauler Date
-- -..----. ---_.__ _.. __- --.-- ----- .......... ....
Signature of Receiving Facility(or attach facility receipt) Date._._. _
t5form4.doc•11/12 System Pumping Record•Page 1 of 1