HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 991 JOHNSON STREET 1/21/2026 t , Commonwealth of Massachusetts
P City/Town of No.Andover
System Pumping Record
Form 4 FEB202
DEP has provided this form for use by local Boards of Health. Other f;*.)r d but the
information must be substantially the same as that provided here. Before using hi w rl your
local Board of Health to determine the form they use. The System Pumping Record must be subm�id 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 -- _ _ --_,.. - G ... �GA� - - --
key to move your Address .—._._. -__ _-_-,-_-- _
cursor-do not
use the return — _....._ ..--- ----...._. - --
key. City/Town State Zip Code
2. System Owner:
Name
reran "•,...*"°
------ _------- --- - ..................-- - -- ---- ---------------
Address(if different froo m location}
No.Andover MA
---- -- -- -.._.—___...--- ----
State -------..---- - - -Zip-
Tel
CitylTownCode
ephone Nai nber
B. Pumping Record
/. /__ P t U
1. Date of Pumping bat 2. Quantity Pumped; -_-._-- ..._.. _.
Gallons
p Cesspool(s) Septic Tank Tight Tank ) Grease Trap
3. Component:
Other(describe): -- ----
4. Effluent Tee Filter present? _� Yes i } No If yes, was it cleaned? _} Yes No
5. Observed condition of component pumped:
--- ----- - - - __ _ _ _ ------ ............ -- - -----_ __.__ -- -----
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic 58 So Kimball St Bradford MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
zla S on---oh S- . — ------- -- --- /2 1/_2 - - —
Signature of Hauler Date
--- - ---- - ---- -- --- -.----------
Signature of Receiving Facility(or attach facility receipt) Date
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