HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 128 JOHNSON STREET 10/23/2025 Commonwealth of Massachusetts
City/Town of No.Andover
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. Be�'ore 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 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. City/Town State Zip Code
2. System Owner:
VQ
IL 0
SAME
Address Cif different from location)
No.Andover MA
----------
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 6a�te �/ 2 Quantity Purnped: ----------------..........
3. Component: Cesspool(s) j/-, Septic Tank Tight Tank Grease Trap
Other(describe).
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Ei Yes I I No
5. Observed condition of comTo nent pumped:
6. System Pumped By:
a e Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 SoMill St/.,Brad d,MA
ature of H'guler date
----------- ------
Signature of Receiving Facility(or attach facility receipt) Date
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