HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 466 WINTER STREET 10/15/2025 G Commonwealth of Massachusetts Town Of NOd AndOVer
w City/Town of No.Andover
System Pumping Record zr
25
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DEP has provided this form for use by local Boards of Health. Other forms may e used, ughe
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 Pun-lping Record must be submitted to
the local Board of Her- th or other approving authority within 14 days fr)m the pumping date in
accordance with 310 '.-MR 15.351.
A. Facility Infok-mation
Important:When
filling out forms 1. System Location.
on the computer, j f
use only the tab
key to move your Address
cursor-do not
use the return __. _ _ -__-__.
key. City/Town State Zip Code
2. System Owner:
VQ
reran
Address(if different from location)
No.Andover ___.._.__. MA
City/Town State Zip Code
Telephone Ni.=»ber
B. Pumping Record
1. Date of Pumping Quantity Pumped:
/coo
Date Gallons
3. Component: ] Cesspool(s) Septic Tank ) Tight Tank Grease Trap
Other(describe): _. ----._ _ .. ........... --
4. Effluent Tee Filter present? j Yes .._ No If yes, was It.cleaned? _; Yes No
5. Observed condition comp nt pumped:
6. System m By: r
C)
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
Signature of Hauler Date
__... --._ _._. -...._.._"' _. _ _._...._ _..._...._ ....__....__.
Signature of Receiving Facility(or attach facility receipt) Date
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