HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1044 SALEM STREET 3/27/2026 Town of Andover
Commonwealth of Massachusetts North
City/Town of No.Andover AIR
System Pumping Record
`Anti Form 4
alto e pie t
DEP has provided this:,form for use by local Boards of Health. Other farms may be use , but the
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
fitting 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:
reh 1 C. f
Name -------- _.--------
rcnan
Address(if different fr,�rer location)
No.Andover MA
City/Town State Zip Code
Telephone Nurnber
B. Pumping Record
1. Date of Pumping Date - 2. Quantity Pumped: - -----
Gallons
3. Component: ] Cesspool(s) XSeptic Tank ( ] Tight Tank � Grease Trap
[__] Other(describe): -
4. Effluent Tee Filter present? ( 1 Yes ] No If yes, was it cleaned? ] Yes ] No
5. Observed condition of component pumped,
6. Pumped By:
—
Nae" -- -._. _.. _.-- Vehicl ee Lic
- -._.e nse,Numb be- .... -r-----------— -------------
Stewarts Septic t:r6 So Kimball St. , Bradford,MA
Company -_.._ ._._ ----
7. Location where contents were disposed:
20 So.Mill St Bradford,MA
Signature of Hauler mate
Signature of Receiving Faciiity(or attach facility receipt) Date
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