HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 100 OLD CART WAY 5/13/2026 Commonwealth of Massachusetts pV n Of NotAndover
w City/Town of No.Andover
System Pumping Record "� N �
4 Form 4P
6tti oeprpp
nt
DEP has provided this form for use by local Boards of Health. Other forms may be us d, u
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: _--
Name ---...........-----__----._._...-----__.------ - ___
return
_.. ----
----_ -- ----- -- --- -._.. -- -- - -
Address(if different from location)
No.Andover MA
City/Town State Zip Code
-----
Telephone Number
B. Pumping Record _
1. Date of Pumping Date - 2. Quantity Pumped: - ----
Gallons
3. Component: i _f Cesspool(s) ptic Tank { ] Tight Tank L ] Grease Trap
Other(describe): -
4. Effluent Tee Filter present? L j Yes o If yes, was it cleaned? --! Yes L--1 No
5. Observed condition of component pumped:
- - -- - --- ------------- ---------— _.__..__.
6. S ste
71-�-
---
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradfor_d_,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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