HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 320 BOXFORD STREET 3/18/2026 Town of Nofth Anciover
Commonwealth of Massachusetts
AIR - 7 2026
_. City/Town of No.Andover
a System Pumping Renard
Forma 4 Health Department
DEP has provided this form for use by local Boards of Health. Other forms may be used, 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
filling out farms 1. System Location
q (r
on the computer, C )
use only
Py thethe tab ...--
key to move your Address -----_ ._.__...._...___ _._...... . _.
cursor-do not
use the return ............................__
key. City/Town State Zip Cade
2. System Owner:
Name ____ __ ___t/4C _ ___
renrn
" Address(if differen#frr�m locatian)
No.Andover MA
CitylTown State Zip Code
Telephone Njrnber
B. Pumping Record
1, Date of Pumping pate 2. Quantity Pumped:
Lallans
3. Component: Cesspools) Septic Tank j Tight Tank ] Grease Trap
Other(describe): ---.__-_--___....._..
4. Effluent Tee Filter present? I ] Yes>1 No If yes, was it cleaned? _ Yes ( .I No
5. Observed condition of component pumped:
..............
6. System Pumped By:
Name _.-----. ----- --
Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
Signature of Hauler Gate
Signature of Receiving Facility(or attach facility receipt) Date
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