HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 4/2/2026 Commonwealth of Massachusetts Town of North Andover
-µ w City/Town of No.Andover
system Ppumping Record MAY - 6 2026
Form 4
DEP has provided this form for use by local Boards of Health. OthJiCrA;t aPAP9VWiR4
information must be substantially the same as that provided here. 3efore using this form, check with your
local Board of Heg1th 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 :110 CMR 15,351,
A. Facility Information
Important:When
filling out forms 1. System Locat;on:
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:
rab
Name
Address(if different from location)
No.Andover MA
- __ _ -_ ._...
City/Town State Zip Code
Telephone_Nu mber
B. Pumping record
1. Date of Pumping Date Z. Quantity Pumped: -- .
Gallons
3. Component: ] Cesspool(s) l `"Septic Tank 1, Tight Tank Grease Trap
_J Other(describe): -- - -___—__.. ..
4. Effluent Tee Filter present" , Yes ] No If yes, was it cleaned? Yes _� No
5. Observed condition of component pumped:
6. S,/stent Pl,lrrlfrerI By:
Name Vehicle License Number
Stewart's Sejtic 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 nor attach facility receipt) Date
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