HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 3 ELLIS COURT 4/20/2026 Cammonweaith of Massachusetts Town Of NOM Andover
MAY --
x City/Town of No.Andover 20 6
System Pumping Record
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. 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,
use only the tab ---- _.__------- �_--- ----- _._..._tllz. ---- ,'_ _.-_.._..
key to move your Address _
cursor-do not
use the return --- _. _ --
key. City/Town _ State Zip Cade
2. System Owner:
rah
_...._..— _._
Name`_______ ----
reran
Address(if different from location)
No.Andover MA
city/Town State Zip Cade
Telaohone Number
B. Pumping Record _
1. Date of Pumping __. 2. Quantity Pumped: � - ---
Date GaPllm-
3. Component: l Cesspool(s) ; _ eptic Tank _� Tight Tank �_ f Grease Trap
Other (describe): ............. _.. __ ............ .._.-.. ..
4. Effluent Tee Filter present? [ .� Yes o If yes, was it cleaned? Yes _ No
5. Observed condition of component pumped:
6. Syste A
ped
Name Vehicle License Number
Stewart s Sep tic 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(or attach facility receipt) Date
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