HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 42 TANGLEWOOD LANE 9/17/2025 Commonwealth of Massachusetts
City/Town of No.Andover 0*4ver
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System Pumping Record OCT
4
Form 4
DEP has provided this form for use by local Boards of Health. Other forms arty be°u, r $ e
information must be substantially the same as that provided here. Before using this form,,, 66 tL v �j oour
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 .................__-- — -..._ 4,15 ,, )�✓ (..
key to move your Address --
cursor-do not w
use the return _ --_-..__ __..-- —_- _-_._._._ _..._.._...
key. City/Town State Zip Code
2, System Owner:
Q ,
__ _ _ -----------------
Name
�emm�
Address(if different Fran location)
No.Andover MA
City/Town State Zip Code
Telephone Nurnber
B. Pumping Record
a te
1. Date of Pumping D - -,�' - -- 2. Quantity Pumped: G--Oon
3. Component: j Cesspool(s) ( 'Septic Tank _I Tight Tank .J Grease Trap
Other(describe); _ -- .. — --- __
4. Effluent Tee Filter present? j Yes o If yes, was it cleaned? Yes _ No
5. Observed condition of component pu ed:
6. Vysm 13
pe . Vehicle License Number
Stewart s Septic, 58 So Kimball St. , Bradford MA
Company
--
7. Location where contents were disposed.
20 SoMill St. ,MA .,.
, ford ,,. _
ignaturej* :PCer - Date
Signature of Receiving Facility(or attach facility receipt) Date
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