HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 885 FOREST STREET 9/17/2025 r n of No►�hAndo
Commonwealth of Massachusetts
µ w City/Town of No.Andover
w° System Pumping Record
Form 4nt
DEP has provided thi:3 form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Berore 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: r
use only he tab
on the
t
computer,
_- ..........__..___.-----
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
VQ 2. System Owner:
Name _ _...._._. _--
ieaan
Address(if dif arent from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: f ors ................._...
Date
3. Components: 1 Cesspool(s) _I eptic Tank j `fight Tank � Grease Trap
Other(describe):
4. Effluent Tee Filter present? j Yesr�mp
o If yes, was it cleaned? ( _] Yes ] No
5. Observed conditi-)n of component ped
6. yslPum ed Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
. _ 2C �
Sig?11 Hauler Date
......__--------------------------
Signature of Receiving Facility(or attach facility receipt) Date
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