HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 TURTLE LANE 10/16/2025 Commonwealth of Massachusetts
City/Town of No.Andover
a
System Pumping Record
Form 4
DEP has provided this form 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
filling out forms 1. System Location. r
on the computer,
Y t
use only he tab P µ /
key to move your Address -- --
cursor-do not
use the return -..._.__.._.._ __ __----,__-- .--____.
key. City/Town State Zip Code
2. System Owner:
r�
,.. i
Name-
SAME
Address(if different from location)
No.Andover MA
---- - -._. - - _- --
City/Town State Zip Code
Telephone Nurrrber
B. Pumping Record
1. Date of Pumping aat� ` ZZ), 2. Quantity Pumped: Gallons
3. Component: j Cesspool(s) X Septic Tank j ] Tight Tank ] Grease Trap
._! Other(describe): -------
4. Effluent Tee Filter present? I' Yes No If yes, was it cleaned? -.. Yes No
5. Observed condition of component pumped:
6. Sy�t ped By'
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 Mauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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