HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 135 CANDLESTICK ROAD 4/16/2026 TOwn of
Commonwealth of Massachusetts Not Andover
City/Town of No.Andover
�A System Pumping Record 2026
MAY
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DEP has provided this form for use by local Boards of Health. Other forms may be use 95plent
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 _................_...._. .....
key to move your Address r.... ... ... ...... _.--.--.__.._.
cursor-do not
use the return - —. __ - ___ ..__... — -
_....._..... ------._ _ ..._ .__----._ _.._ ..._ __. ........_._.....-----
key. City/Town State Zip Code
rya
2. System Owner.
Name
rennin
Address(if different frr5m location)
No.Andover MA
--- ___._....- _ _. - ... . -
City/Town State Zip Code
Te __._.r __-._._ _....__.—
lephone Nu;nbe
B. Pumping Record
1. Date of Pumping Date ._.....__-- -- -_.. 2. Quantity Pumped:
- - _....... .......... ... ..
Gallons
3. Component: .� Cesspool(s) Septic Tank Tight Tank Grease Trap
Other(describe): _._....._....____.._._._...._....
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes No
5. Observed condition of component led
-
6. Syste Pumped By:
Name ns urn er
Stewart's Septic 58 So Kimball St Bradford,MA
-----__-----_----Company
7. Location where contents were disposed:
20 Sri M ,it+St BL or f 1b
A
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) date
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