HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 197 BRIDGES LANE 5/4/2026 Commonwealth of Massachusetts Town of Nofth Andover
r City/Town of No.Andover
System Pumping Record w UN I 2026
a
Form 4
^,
DEP has provided this form for use by local Boards of Health. Other f l d�
information must be substantially the same as that provided here. Before using tisirrtfth 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 CM'R 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab --- - x---- ,
key to move your Address -----------cursor--do not
use the return ---__ _---___.__
key.
City/Town State Zip Code
Q2. System Owner:
Name--- - _____ ----- -- -- _------ ___ - -- -----
{
reran
k6dre ss-0if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - --- 2. Quantit Pum ed:
ba -----
te y p Gallons
3. Component: Cesspool(s) Septic Tank Tight Tank _ i Grease Trap
Other(describe):
4. Effluent Tee Filter present? ] Yes No If yes, was it cleaned? ] Yes I, _j No
5. Observed condition of component pumped:
6. S It Pumped 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 .. p
___ k� WE
Signatu - Hauler w Date
Signature of Receiving Facility(or attach facility receipt) Date
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