HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 125 BOSTON STREET 11/14/2025 " � NorAndover
Commonwealth of Massachusetts
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City/Town of IUo.Andover 12025
System Pumping Record
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 u
Important:When
filling out forms 1. System Location.
an the computer, - ,�°
use only the tab - —._..._ _ _ f '..._ .........
key r _._(�. A,
key to move your Addresscursor--do not
use the return ---- ---------- __ _
key. CitylTown State Zip Code
r�
2. System Owner:
Name --._
ietran
Address(rf different�o-om location)
No.Andover MA
Cit /Town
Y State Zip Code
Telephone Nu¢nber
B. Pumping Record --
1. Date of Pumping Dot __..... 2. Quantity Pumped: Gall an... -_.-._.____.._....
� _ s 3. Component: [ Cesspool(s) I Septic Tank j Tight Tank �_; Grease Trap
j Other(describe): ... ................._.___ __.__-__ ..
4. Effluent Tee Filter present? l Yes If yes, was it cleaned? es ] No
5. Observed condition of component pumped:
... ----_
6.
System Pumped p
" .,, r
f
Nam 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
fgn of Hauler Date
- _ .
Signature.___ of---Re-_ <,eiving Faaiiity- (ar attach__facility--ree- -Date
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