HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 190 GRANVILLE LANE 9/19/2025 Commonwealth of Massachusetts Ver
City/Town of No.Andover OCT 6 2025
System Pumping Record
Y � �
> Form 4 'a
DEP has provided this form for use by local Boards of Health. Other forms may be used, but they
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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: s
on the computer, __ f
use only the tab _...._..._. -- --- _ ..... . . c -- --- -
key to move your Address
cursor-do not
use the return _____._-._....... __..__.. -.-____ ._... ...
key. City/Town State Zip Code
2. System Owner:VQ
'
Na-me.-... . -- .....: _.....
etwn
Address(if different from location)
No.Andover MA
------------ - --- ..--
CityOTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping oat 2. Quantity Pumped:
Ga&s
3. Component: f Cesspool(s) cSeptic Tank [ Tight Tank Trap
_) Other(describe): - -----
4. Effluent Tee Filter present? ] Yes10 If yes, was it cleaned? Yes I No
5. Observed condition of component pumped:
/ , �° A, ,
6. Syste Pump B `.
� 7
N me Vehicle License Number
Stewart's Sep tic_58 So Kimball St. , Bradford,MA
----...--.....-an __
Compa
7. Location where contents were disposed:
ord MA
4�r
Z fiaturwtf` Kler ate
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Signature of Receiving Facility(or attach facility receipt) Date
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