HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 185 MILL ROAD 11/20/2025 Commonwealth of Massachusetts '"Vorth4ndover
City/Town of Vy) Or)A-I)or
a System Pumping Record IEC - 12025
ar Form 4
DEP has provided this form for use by local Boards of Health. Other forms rnay��
information must be substantially the same as that provided here, Before using this form, che.M @4tur
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 out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return
key. City/Town State — Zip Code
2. System Owner.
N
rarm
Address(if different from—location)
City/Town State 21P—Code
Telephone Number
B. Pumping Record
1. Date of Pumping Da I te I 1 2. Quantity Pumped:
G --
al ns
3. Component: Cesspool(s) -Jseptic Tank 1_ i Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present?77--'j Yes I Nallo If yes, was it I cleaned? lYes No
5. Observed condition of component pumped:
6. System Pumped By:
Name
Vehicle LicenseNumber
Stewart's Septic 58 So Kimball St. , Bradford,MA
C-O—Mnarly
7. Location where contents were disposed:
20 SoMill StjBrad rd,MA
O'M
Sis
u e of He r
Signature TofRece`iving Facility attach facility—receijp37t ---
Date
t5form4.doc-11/12
System Pumping Record•Page 1 of 1