HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 200 HAY MEADOW ROAD 4/6/2026 _ Commonwealth of Massachusetts
To o opt paver
x T= City/Town of No.Andover
System Pumping Record MAY
2026
Farm 4
DEP has provided this form for use by local Boards of Health. Other
"ry t
information must be substantially the same as that provided here. B. rye Using this orm, 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 Locatlo
on the computer,
use only the tab ..... -.. �---
key to move your Address
cursor-do not
use the return ._---...... . -----
key. City/Town State — Zip Code
2. System Owner: '
rab o
Name
tB!ulfl
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Nrember
B. Pumping Record
1. Date of Pumping —6 2. Quantity Pumped:
Date Gallons
3. Component: j Cesspool(s) Septic Tank [ J Tight Tank Grease Trap
f ; Other(describe):
4. Effluent Tee Filter present? , Yes No if yes, was it cleaned? Yes _ � No
5. Observed condition of component pumped: "
6. System ped 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 Date
Signature of Receiving Facility(or attach facility receipt) Date
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