HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 60 SHERWOOD DRIVE 4/14/2026 Town
Commonwealth of Massachusetts of arty Andover
-:yp City/Town of No.Andover A -
System Pumping Record
of Farm 4
Health Department
DEP has provided this farm for use by local Boards of Health. Other farms 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 t p out forms 1. System Location:
o -
on the computer,
use only the tab address _.. . -
key to move your
cursor-do not
use the return .... ----- .
key.
City/Town State Zip Code
teb 2. System Owner:
_...._.. _.._._._.._._ M_ .. .... ... ...._ — .-._._._... _,...._..-. .__.... .....
Name
rnnun
Add _tio..._. ------.-
re ss(if diff erent room locan)
No.Andover MA
City/Town State Zip Cade
Telephone Nurnber
B. Pumping Record
1. Date of Pumping Da# - 2. Quantity Pumped:
-- -
Gallons
3. Component: Cesspool(s) Septic Tank I Tight Tank [] Grease Trap
Other(describe); ---------_._-_._...... w........
4. Effluent Tee Filter present? Yes Na if yes, was it cleaned? Yes 1 Na
5. Observed condition of component pumped:
6. S umped 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
Signature of Hauler _ D11 ate
--------.._----- __. _._.._._... .._._...._ ._....._.... .__----__-
Signature of f2eceiving Facili#y(ar at#ach facility receipt) Date
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