HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 721 MIDDLETON STREET 3/31/2026 TOwn
Commonwealth of Massachusetts f A'0* A Y
60 City/Town of NO.Andover
w° System Pumping Record APR 0
-. Y p �
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may 'ta (Ment
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, ,/�,`
use only the tab — -
..............................
key to move your Address __--
cursor-do not
use the return --
key City/Town State Zip Code
VQ 2, System Owner:
Name /
lCfIH71 �0
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping oa 2. Quantity Pumped: Gallons _
3. Component: Cesspool(s) � Septic Tank Tight Tank Grease Trap
Other (describe): ...... ... ...
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes �� No
5. Observed condition of compo nt pumped:
6. System Pu ed By
. .. .. . . . . ..... It1. f
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 Date----
-----................... -----
Signature of Receiving Facility(or attach facility receipt) Date
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