HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 350 HOLT ROAD 5/6/2026 Commonwealth of Massachusetts Town o Andover
City/Town of No.Andover U 0
26
w° stem Pumping Record
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ry.qq Form 4 Health
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DEP has provided this form for use by local Boards of Health. Other forms may be u�setut�t
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, ^157
use only the tab
-
key to move your Address _.._._. . .. _ __.. ---
cursor-do not
use the return key. City/Town State Zip Code
2. System Owner:
re6
s
Name
e�
Address(if different from location)
No.Andover MA
city/7-ow n State Zip Code
Tele ph one Number
B. Pumping Record
t
1. Date of Pumping 2. Quantit Pumped
— od
Date y Gallons
3. Component: Cesspool(s) Septic Tank ; Tight Tank - Grease Trap
Other(describe):
4. Effluent Tee Filter present? es No If yes, was it cleaned? es i ] No
5. Observed coo�ndlftlo of component umped: _
st
G�A
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 S i St.,Bradford,
Sig tur auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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