HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 224 RALEIGH TAVERN LANE 3/16/2026 Town of Nor�h
Commonwealth of Massachusetts Andover
= City/Town of No.Andover
APR 202
System Pumping Record
Form 4
Health Department
DEP has provided this form for use by local Boards of Health. Other norms 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 forms 1. System Location,
c:
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,
rob
Name
Address(if different from location)
No.Andover MA
__.._. ... - -------- --- .-._., _ ._..,... .__,. .__ _ __. --- ...._.......
----
City/Town State Zip Code
Telephone Nurnber
B. Pumping Record
(y
1. Date of Pumping Dot 2, Quantity Pumped: Gallons '
3. Component: 1__j Cesspool(s) `Septic Tank Tight Tank J Grease Trap
Other(describe): - .
4. Effluent Tee Filter present? Yes 1/1 No If yes, was it cleaned? Yes 1 No
5. Observed condition of component pumped:
6. System Pumped B _47-
.._
Name Vehicle License Number
Stewart's Sep6c-58 So Kimball St Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
Signature of Hauler Date
Signature of Recev-irrg I aci1ity 06r attach facility receipt) Date
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