HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 240 RALEIGH TAVERN LANE 11/10/2025 Tow
Commonwealth of Massachusetts n fr AndOVer
r r City/Town of No.Andover
a
System Pumping Record No 102025
Form 4
DEP has provided this form for use by local Boards of Health. Other forms m
information must be substantially the same as that provided here. Before using this form, chec 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
filling out forms 1. System Location:
Imon the 2
portant: y
use onlyhe tab ,
computer,
key to move your Address ..
cursor-do not
use the return _._.----.__ ——- _ _----- ... ---._....
key. City[Town State Zi Code
tab 2. System Owner:
g ,
Name
B SAME
--------- _ .... ---._..._ ---
Address(if different from location)
No.Andover MA
__...----- - - — ------._..._... .__.. --- ......... - - - -._ .......
City/Town State Zip Code
Telephone Number
B. Pumping Record
,w.
1. Date of Pumping D at � 2. Quantity Pumped. _.._......._.__....
Gallons -
3. Component: j Cesspool(s) ._Septic Tank j Tight Tank ] Grease Trap
i _I Other(describe): - — ___._ .............
4. Effluent Tee Filter present? Yes Xo.- If yes, was it cleaned? l ] Yes -_� No
5. Observed condition gof component pumped: y
G ..., .d^+,:a b"'"1 ,^J"1 r' ."` / m ^J"", N Y "'•.
6. System Pumped By:
Name Vehicle Lic nse Number
Stewart s Septic 58 So Kimball St Bradford,MA
Company
7. Location where contents were disposed:
20 So. '.-t radford,MA
Signature of Haule Date
Signature of Receiving Facility(or attach facility receipt) Date
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