HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 328 CAMPBELL ROAD 9/15/2025 Tot"
Commonwealth of Massachusetts lVorth 4ndover
pCity/Town of Co.Andover OCT
System Pumping Record
y
Form 4
DEP has provided this, form for use by local Boards of Health. Other fw rms may
information must be sibstantially the same as that provided here. Bef.�re using this form, checc with your
local Board of Health to determine the form they use. The System Purnping 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 Cade
2. System Owner:
k
_
rznm
Address(f different from location)
No.Andover MA
. wn - -- --- ---- - - --._ _.._.__.. -- ___ ---- __-co ......
---e------------
City/"rown State Zip Code
'rElephone Nur 7ber ---
___.__. __.___ _.._....__....
B. Pumping Record
1. Date of Pumping - - 2. Quantity Pumped:
Date talons
3. Component: Cesspool(s) Septic Tank ] 'Fight Tank ; _ 'i Grease Trap
Other(describe): - .... . .... - -- ------ -
4. Effluent Tee Filter present? Yes o If yes, was it cleaned? Yes i. No
5. Observed condition of component pumped:
+
Pu pe y:
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 att,;+ch facility rer,�eipt) Date
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