HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 248 BRIDGES LANE 11/5/2025 Commonwealth of Massachusetts TOWJ7 Of Nc)dh And,'Ver
City/Town of .No.Andover
DEC - 1
System Pumping Record 2025
Form 4
De ap �fjent
DEP has provided this form for use by local Boards of Health. Other forms may be used, but h
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 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab Z_
key to move your Address U
cursor-do not
use the return
key. City/Town State Zip Code
Z System Owner:
feb
Name - ---------------------------
SAME
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Nuanber
B. Pumping Record
1. Date of Pumping Dat 2. Quantity Pumped:
Gallons
1
3. Component: Cesspool(s) �Sptic Tank 1,- I Tight Tank Lj Grease Trap
li 11 Other(describe): ................
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? (.'�/Yes No
5. Observed condition of compone t pumped:
�
6. Syf2stePum ed B
Na Vehicle License Number
ts
St rt's Seplkq_58 So Kimball St. , Bradfoll
------------
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradfoll
Signature-of-Hauler—
-------------
Signature of Receiving Facility(or attach facility receipt) Date
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