HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 STANTON WAY 4/9/2026 Town
Commonwealth of Massachusetts of North 11ddVeI"
City/Town of NO.Andover MAY - 2026
_ System Pumping Record
- Form 4 �q a 1 p^��1t6rr0,�y �y
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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
an the computer, e C C�d`
use only the tab _.._------...... _.. ---_= // -.
key to move your Address _..
cursor-do not
use the return .............----------------- - -
-
key. City/Town State Zip Code
2. System Owner:
Name ...... . _....
/Rl7H7f
Address(if different fmm- location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping I�acord...�..�._____
1. Date of Pumping bate 2. Quantity Pumped: Gallons ---
3. Component: ] Cesspool(s) Septic Tank Tight Tank �_j Grease Trap
Other (describe):
4. Effluent Tee Filter present? ) Yes I o If yes, was it cleaned? Yes No
5. Observed condition of component pumped
6. System Wimped 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
_.._.__ .. — __ ---__ _..._......_....___ ........._ ...-....
raf auler Date
------------------
Signature of Receiving Facility(or attach facility receipt) Date
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