HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 BOSTON STREET 10/29/2025 Commonwealth of Massachusetts
=-x City/Town of No.Andover
w° System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other farms 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 Hea,'th or other approving authority within 14 days from the pumping date in
accordance with 310 ("WR 15.351.
A. Facility Information
Important;When
filling out forms 1. System Location:
on the computer, I
use only the tab ��ri
key to move your Address
cursor-do not
use the return
key.
City/Town State Zip Code
2. System Owner:
Q
Name
SAME
--- _ --------- ---._._--------—-- ._.._._...
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Njmbe-r
B. Pumping Record
_..... _
1. Date of Pumping
_ Quantity Pumped:p g Date y p d�flons
3. Component: ] Cesspool(s) Septic Tank Tight Tank �_ , Grease Trap
Other(describe): -
4. Effluent Tee Filter present? i _� Yes No If yes, was it cleaned? E ! Yes [ ) No
5. Observed condition of component p6mped.:.)
_.......... ._ - .............
_ - -----_
0
6. Syste.r /Pumpp`/43y�,,"1 f
Na e L _.__ — _..... ....... Vehicle YLi
cense Number
Stewart s Septic 58 So Kimball St Bradford,MA
Company _..
7. Location where contents were disposed:
20 So Mill,,St prdford M/ ,
�Sfghat
ore of Date
Signature of Receiving Facility(or attach facility receipt) Date
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