HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 57 CHRISTIAN WAY 12/1/2025 Commonwealth of Massachusetts
w' City/Town of irlo.Andover
System Pumping Record
~� W 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 He;.,Ath or other approving authority within 14 days R'rom the pumping date in
accordance with 310 CIVIR 15 351. To\un of Andover
A. Facility Information , ky
Important:When 3AN
filling out forms 1. System Location:
on the computer,
key
only the b ....--- .. . - --
- - - —
ke to mave our Address
cursor-do not
use the return
key. City/Town _ _ __ State - Zip Code
2. System Owner`
reb
1
Name
re2an
Address(ef different `ram lacatiarr)
No.Andover MA
City/Town State Zip Code
Teiephone Number
B. Pumping Record
1. Date of Pumping Date ___ ..___.__._. 2. Quantity Pumped: d.Iao
allons
3. Component: Cesspool(s) _ Septic Tank 'i Tight Tank _) Grease Tr p
Other(describe): ----- --. - . -- .._---
4. Effluent Tee Filter present? ] Yes [ No If yes, was it cleaned? Yes No
5. Observed condition of component pumped. ,
6. System Pumped By:
----- — ._....
Name Vehicle L ice n�.9 Number
Stewart's Septic 5�8 So Kimball St , Bradford,MA
Company
7. Location where contents were disposed:
20 So Mill St Bradfor A
------------
a,
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11/12 System Pumping Record•Page 1 of 1