HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 356 RALEIGH TAVERN LANE 4/10/2026 Commonwealth of Massachusetts 'Town of MOO Andov,�,r
w City/Town of No.Andover
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System Pumping Record
Form 4
Her
DEP has provided this form for use by local Boards of Health. Other forms may be u'fie ;`buf the m
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, A-Z
use only the tab ar. e/-_____ .._.. :.-t /I..--_.._.
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code ---
2. System Owner:
Q '" l
Name - ---
ienun
Address(if different from location)
No.Andover MA
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping as -. - --- 2. Quantity Pumped: Gallons__
3. Component: Cesspool(s) Septic Tank Tight Tank ��_ 1 Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes k No If yes, was it cleaned' Yes No
5. Observed condition of component pumped:
6. SystsIn um ed By'.
k
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
q
Signature of Hauler _- Date
Signature of Receiving Facility(or attach facility receipt) Date
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