HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 51 STANTON WAY 11/20/2025 Commonwealth of Massachusetts AM llh AndoVer
x� City/Town of Jo.Andover
System Pumping Record
/f Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be Us ', Wt Ment
information must be substantially the same as that provided here. Betore using this form, check with your
local Board of Health io determine the form they use. The System Pulping Record must be submitted to
the local Board of Health or other approving authority within 14 days (,0m the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location.
on the computer, t /
use only the tab ___....._-----__--------------
. .__... 57
_._..___._ _..._.___ C - ---_....... ..... ...--.---.. ...._. ._.._
key to move your Address
cursor-do not
use the return
key. Cityn
'own State Zip Code
2. System Owner:
Name
Y8h#7f
Address(if different f+om location)
No.Andover MA
City/Town State Zip Code
Telephone Nurr,ber
B. Pumping Record
1. Date of Pumping Datf_ /�, >..-... 2. Quantity Pumped:
a ,
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:
& System Pumped By: G �`
Name Vehicle License Number
Stewart's Septic 58 So Kimball St , Bradford,MA
Company
7. Location where contents were disposed:
20 So. 0I t radfor A
Signat e f ler Date
Signature of Receiving Facility(11 or attach facility receipt) Date
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