HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 97 BRADFORD STREET 11/10/2025 Commonwealth of Massachusetts O - 025
City/Town of No.Andoyer
System Pumping Record i o a t
Form 4
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 CMR 15.351.
A. Facility information
Important:When
filling theout
coforms 1. System Location: . — -
on the computer,
use only the tab F 1 ! "
key to move your Address
cursor-do not
use the return
key. City/Town State
rak r -- . Zip Code
2. System Owner: "
,-X 1�
Name
Address(if diffi ere nt fr"'om location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record µ
1. Date of Pumping e 2. Quantity Pumped: Gallon
Dats
3. Component: Cesspool(s) Septic Tank Tight Tank ; Grease Trap
Other(describe): _ _ - _........
4. Effluent Tee Filter present? i ] Yes I—T*o If yes, was it cleaned? ] Yes �,-'F~No
5. Observed co dition of comp nt ptnped
, .
. .
6. System umped By'. <
Name Vehicle License Number
Stewart's Septic 58-So Kimball St 13radford,MA.
- ._.._.._..._...._._
Company
7. Location where contents were disposed:
o.Mill St.,Bradf�Cd,MA
Date
Signature of Receiving Facility(or attach facility receipt) Date
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