HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 59 WILLOW RIDGE ROAD 9/29/2025 Commonwealth of Massachusetts ro Wj? ( f� r,
u City/Town of No.Andover
System Pumping Record OCT
Form 4 6 2025
?fl.
DEP has provided this form for use by local Boards of Health. Other fc rms ��j b(f'� � bqt the
information must be substantially the same as that provided here. Before using this fo ;Wong our
local Board of Health :o determine the form they use. The System Pumping Record must be subi��tted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 C IVIR 15.351,
A. Facility Information
Important:When
filling out forms 1, System Location:
on the computer,
p _.. .. .._.. . _ _..._
ab
key Y the to move t our Address � � _F" C =G✓ �'--- '�--" -_--
cursor-do not
use the return —_.__—_ _
key.
City/Town State Zip Code
t� 2. System Owner:
Y i
Name
enun SAME
Address(if different from location)
No.Andover MA
— ---- ---__._ - -- - --_.--
City/Town State Zip Code
Telephone Nuanber
B. Pumping Record
1. Date of Pumping _ ___ 2. Quantity Pumped; - - --.__
Date Gallons
3. Component: Cesspool(s) Septic Tank 1-ight Tank i'__1 Grease Trap
Other(describe): ----___-_
4. Effluent Tee Filter present? .� Ye No If yes, was it cleaned? j Yes L No
5. Observed condition of component pumped:
..... _. _____. ._._._ .._ . . _.._._. _.. __.. _. _ ..
& System Pumped By:
-- ----------
Name Vehicle License Number
Stewart s Septic 58 So Kimball St. , Bradford,MA
p Comany
7, Location where contents were disposed.
20 So.Mill St.,Bradford,MA
_._.—.�
Signature of Hauler Date
_..._..._.._.._ _ ------ -....._....._., -- - ---
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1