HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 104 BRIDGES LANE 10/6/2025 Commonwealth of Massachusetts own of lVorti"
City/Town of No.Andover
W_- w System Pumping Record OCT.
�.- 4 ���Form
DEP has provided this form for use by local Boards of Health. Other forms �.It� the
information must be substantially the same as that provided here. Before using this f rr c I �cepyth your
local Board of Health to determine the form they use. The System Purnping 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:
on the computer,
use only the tab .-.._ ---- _._.. _ /� -— _ _ __._.................-._...-_ --
key to move your Address
cursor-do not
use the return _.--------------_._------____ - -____
key.
City/Town State Zip Code
r�
2. System Owner:
Name
anrnn
Address(if different from location)
No.Andover MA
_....... ......_. - ---_. ......----- --. _.._
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping date < " 2. Quantity Pumped:
all ons
3. Component: [ Cesspool(s) Septic Tank ; Tight Tank i
I I Grease Trap
Other(describe): - ----------- _. __..__ ._................
4. Effluent Tee Filter present? l Yes i r, No If yes, was it cleaned? :i Yes .� No
5. Observed condition of component pumped:
& System Pumped B
C.J
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford MA
Company
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
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