HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 4 LACY STREET 11/6/2025 Commonwealth of Massachusetts Town �,-J Wh Andover
City/Town of No.Andover DEC - 12025
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System Pumping Record
Form 4
HeaKh, Department
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
2. System Owner:
................
Name
SAME
;ka-d-r-e--s--s-(i-f--di-ffe-r-e-n-t-f-rc-)m—loc—ati-o-n--)---------- --------------------
No.Andover --------- MA
---- ------
City/Town State Zip Code
Telephone Nurnber ---------
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped.
Hors
3. Component: Cesspool(s) Septic Tank Tight Tank Grease Trap
Other(describe): ------- --
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? --j Yes I<No
5. Observed condition of component pumped:
--------------------- -----------........--------
6. System Pumped By:
,-7 0 b IL" 1 5
-------1 m- - - -----
Nla 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
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-Date
Signature of Receiving Facility(or attach facility receipt) Date
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