HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 476 JOHNSON STREET 4/20/2026 lown f ivorth n
Commonwealth of Massachusetts ®��r
w City/Town of No.Andover 202
° System Pumping Record e �
Farm 4 ashy
DEP has provided this form for use by local Boards of Health. Other forrns 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 forms 1. System Location: ry
on the computer, a�+ _ _..
use only the tab _... ._��� �,.. G�"� .�-----_._...------__._. ---..............
key to move your Address
cursor-do not
use the return ... ..........- --- ---.. ,.
key. City[Town State Zip Code
2. System Owner:
rennn
Address(if different from location)
No.Andover MA
---- _..._._ --------- ___ -- _ _- ---.—_._, ... - .... ............ _...----
CityrTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping o.t/-G�
._ 2. Quantity Pumped:
Gallons
3. Component: L _1 Cesspool(s) Septic Tank ] Tight Tank Grease Trap
Other(describe): -- -__. _........
4. Effluent Tee Filter present? Yes tA No If yes, was it cleaned? l Yes No
5. Observed condition of component pumped:
6. System Pumped 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
_ ..._
Signaturey auler Date
_._. ..._ ____. .------ --._._ .... ......_.__.
Signature of Receiving Facility(or attach facility receipt) Date
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