HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1000 TURNPIKE STREET 12/2/2025 Commonwealth of Massachusetts t
Andover
w City/Town of No.Andover
w
System Pumping Record 0
,.>ew
Farm 4
DEP has provided thi form for use by local Boards of Health. Other harms may
information must be sijbstantially the same as that provided here. Before using this form, check with your
local Board of Health mo 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 ("MR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location,
on the computer, �°° �� ,�
use only the tab -- g� �r __ 7 -.-------
key to move your Address
cursor-do not
use the return __.._.. -------__ ------- _ _-----
key.
City/Town State Zip Code
2. System Owner.
Name
/6tlNil
Address(rf different from locatson)
No.Andover MA
City/Town State Zip Code
Telerrhone Number
B. Pumping Record
.a --
1. Date of Pumping DZe /C�W_ _5 2. Quantity Pulrtped:
Gall s
3. Component: Cesspool(s) iiSeptic Tank Tight Tank - '� Grease Trap
Other(describe): __ _ ............. .....
4. Effluent Tee Filter present? 1 Yes ( o If yes, was it cleaned? l Yes f No
5. Observed condition of component pumped;
5. Sys Pu d i3y:
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 facil ty receipt) Date
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