HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1515 SALEM STREET 10/2/2025 Commonweaith of Massachusetts Town of Noth, Andover
u City/Yawn of No.Andover V 10 2025
w System Pumping Record
r,. Form 4
h Department
DEP has provided this form for use by local Boards of Health. Other farms 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 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, °r"
use only the tab -- f ..w. /
key to move your Address __ _ _..
cursor-do not
use the return
key.
CityfCown State Zip Code
Q 2. System Owner:
�
Name
e SAME
Address(if different from location)
No.Andover MA
Cityffown State Zip Code
Te"ephone Nurnber
B. Pumping Record
.._..M.
1. Date of Pumping - - 2. Quantity Purrtped:
Gallons
3. Component: Cesspool(s) Septic Tank .,. Ti ht Tank _ Grease Trap
-; Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? ] Yes No
5. Observed condition of component pumped:
n �
6. System Pumped By:
/ _ �S __. ............ __._ _....... ... . _...
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 gg
Signature of Nauler Date
Signature of Receiving Facility(or attach facility receipt) Date
f
i
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