HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 175 STONECLEAVE ROAD 4/1/2026 Commonwealth of Massachusetts Town of NoM Andover
x g� City/Town of No.Andover
System Pumping Record MAY 2026
r Form 4
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DEP has provided this form for use by local Boards of Health. Other fNQ"fNPA9@gM@nt
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
cursor-do not
use the return --- — --
key.
City/Town State Zip Code
2. System Owner:
Cab
____z
Name — — -- ------------
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Address(if difFwrent from location)
No.Andover MA
- ---.... ............... ............._.
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ............... 2. Quantity --- --------�.._
p g Da�e///Cuan y 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? j Yes [ ] No
5. Observed condition of component pumped:
d
6. S Pumped By:
--- -- --- -. - ---- ....--. ....... -- - -- - - - --- -
Name Vehicle License Number
Stewart'-6 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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