HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 19 BRADFORD STREET 10/9/2025 `- Commonwealth of Massachusetts
W City/Town of No.Andoyer
System Pumping Record
ll_qq' W Form 4
DEP has provided thi:; farm for use by local Boards of Health. Other forms 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 CMR 15.351.
A. Facility Information -
Important:When
use onlythe tab _.__.---.__ _ ___. ___.__.. ��r ' [__
filling out forms System Location.
on the computer,
� C r`� 6 ;" Q
key to move your Address -- —, ----._
cursor-do not
use the return --- _._.__ __ _.__..
key City/Town State Zi Code
2. System Owner:
" .
Name
SAME
_...._-- --._.— ----cati-. ..
Address-ss(if different tram loon)
No.Andover MA
c i y/Town State Zip Code
Telephone NGamber
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: .t _ ..__.-
GaWOnS
3. Component: j Cesspool(s) eptic Tank [ Tight Tank Grease Trap
Other(describe): ..... ..--- __.......
4. Effluent Tee Filter present? ] Yes J0 If yes, was it cleaned? Yes ..0 No
5. Observed condition of component pumped:
c --
6. Sys ern um e
Nam Vehicie License Number
Stewart s Septic 58 So Kimball St Bradford,MA
Cop
_...._.
many
7. Location wh
ere co So_Mill t Bta ntents were disposed:
20
h �.._._ ~ ..
MA
ignature of Ha er " bate
Signature of Receiving Facility(or attach facility receipt) Date
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