HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 128 BRADFORD STREET 10/6/2025 Commonwealth of Massachusetts
N City/Town of No.Andover OCT
ry System Pumping Record
Form 4Health C
DEP has provided this form for use by local Boards of Health. Other forms may be used, but Q
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: _---
use only the tab
on thehe tabcomputer,
----__..-__-__ ..._._ _ _.__
key to move your Address
cursor-do not
use the return — ...
key. City/Town State Zip Code
VQ 2. System Owner:
Name
reMn
__--------
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Nu~iber
B. Pumping Record �d
1. Date of Pumping Da 2. Quantity Pumped: CA ons
3. Component: Cesspool(s) Septic Tank ] Tight Tank Grease Trap
_j Other(describe): _.... _. ___.
4. Effluent Tee Filter present? 1 _j Yes , _No If yes, was ii:cleaned? I Yes No
5. Observed condition of co anent pumped:
6. Sy m P roped y.
Na e 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
Si nature of Receiving Facilit y p)
g , y(or attach faciht recei t date
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