HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 10 HAWKINS LANE 11/14/2025 rt
G Commonwealth of Massachusetts r)dover
r City/Town of No.Andaver DEC2025
n
System Pumping Record
Form 4 ' `� Departrnelt
DEP has provided thin 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
fillip out forms 1. System Location:
on the computer,
g Y
use only the tab ..
key to move your Address e - .......... —.......
cursor-do not
use the return — _ --.._..- _ .....
key. City/Town State Zip Code
Q
2. System Owner:
gym:
Name — -
rBA�, SAME �"
Address(if different from iocation)
No.Andover MA
City/
---To--w--n._" .- — State—_ Zipp Code-------------- - --. . - -
...... . _
Telaohone N-L�n'b"e-r--
B.
Pumping Record
1. Date of Pumping 2. QuantityPumped:
--
p g Dat
um p Ga Ions
3, Component: Cesspool(s) 'Septic Tank _ Tight Tank _ Grease Trap
Other (describe): __...— -..__.._-- _._.... ......_
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? �' Yes No
5. Observed condition of component pumped:
c
6. System Pumped By:
Z _03 0 r1 -
Name 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
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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