HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 61 WHITE BIRCH LANE 11/4/2025 Commonwealth of Massachusetts Town of NO*Andover
City/Town of
DEC - 1
S System Pumping Record 2025
Form 4
Health p,�aoltaxnt
DEP has provided this form for use by local Boards of Health. Other forms may
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 CIVIR 15351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab ..(gjti I-C h L_�Pq_
key to move your Address ..........
cursor-do not
use the return
key. City/Town State Zip Code
VQ 2. System Owner-,
Name
Address(if—different from—location)
Zip Code
e
Telephone Number ------�
B. Pumping Record
1. Date of Pumping '2. Quantity Pumped:
Date Gallons
3. Component: Cesspool(s) [V�" Septic Tank Tight Tank j Grease Trap
Other(describe):
r
4. Effluent Tee Filter present?Y_ Yes If yes, was it cleaned ied es r No
5. Observe—condition of component pumped:
6. System Pumped By:
4h
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
'T;-egn,"ue I dule
Date
ignature of Receiving Facility_(or attach
Cfa�c t Date
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