HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 62 GRANVILLE LANE 9/10/2025 Commonwealth of Massachusetts
City/Town of No.AndoverOCT0
25
w System Pumping Record
Form 4
DEP has provided this farm for use by local Boards of Health. Other forms may be used, but twnt
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 ,31VIR '15,351.
A. Facility Information
Important:When
filling out forms 1. System LOcatlOrl: �
on the computer,
use only the tab
-—
key to move your Address _ - - — — — -----
cursor-do not
use the return __.._ ___ _-..._key.
C�tylTown State Zip Gode
I 2. System Owner; 1
Name
rer�rn
Address(if different from location)
No.Andover MA
CitylTown State Zip Code
Telephone iriber
B. Pumping Record N
1. Date of Pumping 2. QuantityPurn ed:
Date p Gallons
3, Component: Cesspool(s) Septic Tank j Tight Tank .] Grease Trap
Other(describe): -------- _._ - --- --- -- -
4. Effluent Tee Filter present? I 1 Yes ,� No If yes, was it cleaned? J Yes i No
5. Observed condition of component pumped:
___ ---------- .._. . ....
6. Sys t mped By
Name Vehicle License Number
Stewart s Septic 56 So Kimball St Bradford,MA
-._ --- _ .....................
Company
7. Location where contents were disposed:
2G Sca m-E-rt ,oxd MA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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