HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 21 CLARK STREET 12/19/2025 Gam, Commonwealth of Massachusetts Town of North Andover
x City/Town of No.Andover
System Pumping Record JAN ZO
Form 4
M Heal
DEP has provided this form for use by local Boards of Health. Other forms may ent
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:
on the computer,
use only the tab ---_._. ( :.a
key to move your Address
cursor-do not
use the return _.__.......... . _._..._.
key. City/Town State Zip Code
reb 2. System Owner:
Name
ierorn
Address(if different from location)
No.Andover MA
CAyf_Tawn State Zip Cade
Telephone Number _._.
B. Pumping Record
1. Date of Pumping t -------- 2. Quantity Pumped:
Gallons
3. Component: ; Cesspool(s) I Septic Tank Tight Tank ;. ] Grease Trap
Other(describe): __ .__. __. --_ ..... _ --
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? ] Yes _j No
5. Observed condition of component pumped:
6. Sys#��1�mped By
_._._ !�)_ .__ 1111111-11- ._..... ------- _- --
Name Vehicle License Number
Stewart's Sertic 58 So Kimball St Bradford,MA
_.. ..---___ _..........
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
-. _.._..._.... —. _ .............
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