HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 11 CHERISE CIRCLE 9/26/2025 Commonwealth of Massachu rt1 % ,setts
W City/Town of k'�o.Andover �
System Pumping Record
Form 4 "
DEP has provided this; form for use by local Boards of Health. Other f,)rrns may be used, but the
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 trom the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
m uter,
use only the tab
key to move your Address -------------------_..._._ ____.
cursor-do not
use the return --------- —------
key. City/Town State Zip Code
2. System Owner:
Name _._.
remm
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telept�onr.fs`i�snber
B. Pumping Record
1. Date of Pumping Date 2. Quantity Purnped:
Gallons
—- --
3. Component: Cesspool(s) eptic Tank Tight Tank Grease Trap
Other(describe): ---- -- _ --.__
4. Effluent Tee Filter present? es No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
& i Pumped By
t
Name Vehicle Lcers Number
Stewart's Septic,,58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
'77-
Signatur61`Hauler bate
Signature of Receiving Facility(or attach facility receipt) bate
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