HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 511 WINTER STREET 11/14/2025 Commonwealth of Massachusetts V/ Andover
N City/Town of No.Andoyer
System Pumping Record DEC 05
p' Form 4
DEP has provided this form for use by local Boards of Health. Other forms may b
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
filling out forms 1. System Location:
on the computer, / s,
use only the tab
key to move your Address
cursor-do not
use the return ___._____.. ............_......
key.
City/Town State Zip Code
Q2. System Owner:
Na__me .........
. .. .--- .........
nmran
Address(if different fr:)m location)
No.Andover MA
---- --..--
City/Town State Zip Code
Telephone Nu �rner
B. Pumping Record
1. Date of Pumping oat % Quantity Pumped: lip _
3. Component: Cesspool(s) -
p f � j Septic Tank [ � Tight Tank �� Grease Trap
Other(describe):
4. Effluent Tee Filter present? ) Yes 1 No If yes, was it cleaned? l ] Yes _'; No
5. Observed condition of component pumped:
6. System Pumped .3y.
--_-_
Name Vehicle License Number
Stew --. __.._._
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
Signature of Hauler Date
_ - ...---- ---- __...... . .._.._.... -----..__..-.._ ----- - — _....._.......
Signat_uure of Receiviti^,�Facility(or attach facility receipt) Date
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