HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 HAY MEADOW ROAD 5/15/2026 Commanweaiith of Massachusetts Town of North Andover
- =�W City/Town of No.Andover
w" System Pumping Record
/= Form 4 ,NAB [Department
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1• System Location.
on the computer,
use only the tab _.__ __-_ __..._ r �`.''" -..L
key to move your Address ___
cursor-do not
use the return ---__ ......... ...._...__._-_._ __ ... .........
key.
City/Town State Zip Code
2. System Owner:
rab
Name
ranun f°-
Address(if different fr m- location)
No.Andover MA
City/Town State Zip Code
Telephone Nun+be-
�cord
Pumping �'
w
1. Date of Pumping '' 2. QuantityPumped:
Da p Gallons
3. Component: Cesspool(s) ° * Septic Tank Tight Tank i Grease Trap
Other (describe): -------._..._ _................., ,
4. Effluent Tee Filter present? es No If yes, was it cleaned? ' Yes _ No
,Yl
5. Observed condition of compo ent pumped
-- ... ...
6. S Y"st n, umped By: "
Name Vehicle License>.Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.MIIj Bradford MA
- -
,, .
HauTer Date
Signature of Receiving Facility(or attach facility receipt) Date
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