HomeMy WebLinkAboutTight Tank - Septic Pumping Slip - 21 CLARK STREET 12/19/2025 min
Commonwealth of Massachusetts oof NOfth Andover
w City/Town of r4o.Andover
System Pumping Record
gyp^ Farm 4
e�qh,
DEP has provided thi ,, form for use by local Boards of Health. Other forms may bPLRW4Ment
information must be sr.lbstantially 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 He-with or other approving authority within 14 days tom the pumping date in
accordance with 310 '`,MR 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 f A
Name
11-
Address(if different freAm Vocation)
No.Andover MA
Gity/Town State Zip Cade
Te-lephar e Nt.nber
B. Pumping Record
1. Date of Pumping p t 2. Quantity Pumped: _.._._
Lallans
3. Component: j Cesspool(s) ] Septic Tank ,Tight Tank �_ Grease Trap
_I Other(describe): __.. ----_.__-_..__.....____ ......_.
4. Effluent Tee Filter present's � _ Yes No If yes, was it cleaned? 1 Yes � _J No
5. Observed condition of component pumped:
6. Syst umped By
Name veh�lcie License Number
Stewart's Septic 58 So Kimball St. , Bradford MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
_ __.
_.,_.a----e--of
Signtur- of Ha r date h
Signature of Receiving Facility(or attach facility receipt) Date
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