HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 62 FULLER ROAD 11/3/2025 Commonwealth of Massachusetts
=- City/Town of INo.Andover Town f Nofth Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Oth � Aus"eb t e
information must be substantially the same as that provided here. r "t51 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
fining 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:
rya
Name _. _ ----------
SAME
` Address(if different 66� n-location)
No.Andover MA
- --.._ _ ...___.__ — - _- --. - --. ._..w
Cjty/Town State Zip Code
Telephone N L6rber
B. Pumping Record
1. Date of Pumping f 2. Quantity Pumped: ........ _-
Date GIlons
3. Component: f Cesspool(s) Septic Tank Tight Tank ,� Grease Trap
_.� Other(describe): -- --_ _— ____
4. Effluent Tee Filter present? Yes ` , No If yes, was it cleaned? _ Yes I No
5. Observed condition of component pumped:
6. Syste Pumped By:
Name _ Vehicle License Number
Stewart s Septic 56 So Kimball St Bradford MA
Company
7. Location where contents were disposed.-
MA
nature of uler Date
signature of Receiving Facility(or attach facility receipt) Date
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