HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 705 MIDDLETON STREET 11/21/2025 Town ) tlnog
Commonwealth of Massachusetts er
C City/Town of No.AndoverDEC
2025
System Pumping Record
' .
" Form 4
pa
DEP has provided this; form for use by local Boards of Health. other farms may be used,
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health ,,.o 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 lnfcfrmation
Important:When
'in the computer,l1. S Stem Location:
o
use only the tab �,� / f� �✓"N /��'"°".�fC .�„..� � ~`,, "r �
.........-___._—_ ___.
key to move your Address
cursor-do not
use the return __._.._ ____ _..__.. .............
key.
City/Town State Zip Code
2. System owner.
Name
Address(if different from location)
No.Andover MA
Gity/Town State Zip-Code
Telephone Number
B. Pumping Record
1. Date of Pumping date _- 5 .. ° . 2. Quantity Pumped: Gallo
3. Component: Cesspool(s) eptic Tank , Tight Tank Grease Trap
_� Other(describe): _. ....__.. _.__ -- -.-
4. Effluent Tee Filter present? Yes If yes, was it cleaned? Yes I No
5. Observed condition of component pumped:
& Syste Pumped By:
....... . ___.. ........
Name Vehicle License Number
Ste .. tic..... __ ----- _--_._._.. _--___..._
Company
T Location where contents were disposed:
20 So Mill St B/rd,MA
- Jr _
+ kure of uler _. _ Da
Signature of Receiving Facility(or attach facilitye
.r._ce. ip_.
t) Date
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