HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1 BRECKENRIDGE ROAD 10/2/2025 Commonwealth of Massachusetts ul'140rttl Andover
City/Town of
System Pumping Record NOV 10 2025
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may b ihsbrati I
information must be substantially the same as that provided here. Before using this form, check wi tl 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 CIVIR 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. CityfTown State Zip Code
2. System Owner.
Name
raom
Address(if different from location)
�ity,7ow�n ��— 'State Zip Code
TelephoneNumber ��
B. Pumping Record
1. Date of Pumping
Date 2. Quantity Pumped: �;a ions
3. Component: Cesspool(s) V Septic Tank Tight 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:
9 0c)
6. System Pumped By:
/�Ict-sop
Name
Vehicle License Number
Stewart's Septic 58 So Kimball St. , Br;;dford,MA
Company
7. Location where contents were disposed:
20 SoMill St.,,BradfordMA
Signature of Hauler- ate
Signature of Receiving�Facirty
(or attach facility—receijp3t)--- Date
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