HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 67 CRICKET LANE 11/6/2025 Commonwealth of Massachusetts
w� City/Town of No.Andover DEC O 25
�x System Pumping Record
W Y p g
py ..
0 Form 4
Pa
rtment
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 Purnping 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
filling out forms 1. System Location'
on the computer,
use only the tab _ t r -
key to move your Address - - -- --
cursor-do not
use the return -- _ ----------.___
key. City/Town State Zip Code -------
2. System Owner:
Q
----
atum `
--._...--._.._. --------------....__._.. _.. -- --- ----------
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping -� - 2. QuantityPumped:Date um p Gallons...— ------ -
3. Component: ] Cesspool(s) Septic Tank I _I Tight Tank �_� Grease Trap
Other(describe): _.-_----------------.---___._...___----_.___..._..__.
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? l Yes o
5. Observed condition of component pumped:
t
6. System Pump d By
.,
Name 'Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill
--- _ --------- -- ---._._ -
..,...... Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1