HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 114 LACY STREET 4/20/2026 Commonwealth of Massachusetts
x
City/Town of No.Andover MAY 202
System Pumping Record
j Form 4 Department
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. Benore 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, / -w
use only the tab __----- --(-`-- t _
key to move your Address
cursor-do not
use the return ---___ -------- _
key. City/Town State Zip Code
reb 2. System Owner:
,........____-.---
Name _..............------ -
r�nan
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping -- 2. Quantity Pumped:
Gallons
3. Component: j Cesspool(s) eptic Tank Tight Tank �r Grease Trap
Other(describe);
4. Effluent Tee Filter present? ] Yes No If yes, was it cleaned? ] Yes (� No
5. Observed condition of component pumped:
r
_. _ __.
6. System P7ped By
a
Name Vehicle License Number
Stewart's Septic 5$ So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 S itf7srBradford,MA
.. ---
Sinrai - __ Date
Signature of Receiving Facility(or attach facility receipt) Date
---- ...._ ----__ _.....-------
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