HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 STANTON WAY 4/16/2026 Commonwealth of Massachusetts TGWn of NOfth Andover
-- City/Town of No.Andover MAY
System Pumping Record
_ w
®.ry Form 4Heafth eat en
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
tilling out forms 1. System Location:
on the computer, la,��
use only the tab
key to move your Address
cursor-do not
use the return --_ .............. __ _.__.__-_
key. City/Town State Zip Code
2. System Owner:
Name
18fld7!
Address(if different from location)
No.Andover MA
-- --.._.._..... _ --- ..........
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping -- _._ 2. Quantity Pum ed: _
p g Date y p Gallons- - -�
3. Component: �� � Cesspool(s) t Septic Tank Tight Tank [ Grease Trap
j Other (describe): -- ---- --------- -_...._..
4. Effluent Tee Filter, present? Yes No If yes, was It cleaned? > Yes j No
5. Observed condition of co pop nt 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 ord,MA
- ....... .
raa__._ -.-._____ _._..._--
g � Crate
Signature of Receiving Facility(or attach facility receipt) Date
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