HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 18 EQUESTRIAN DRIVE 5/27/2026 "rl Of K10fthAndover
'= Commonwealth of Massachusetts
- 6 City/Town of No.Andover .
2026
System Pumping Record
Form 4
' ec fth t
DEP has provided this form for use by local Boards of Health. Other forms may be sedlruot
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 ;,MR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, / D
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
Name -..
rmran
Address(if different fmrn location)
No.Andover MA
-- - _ .-..
CitylTown State Zip Code
Telephone Number
B. Pumping Record
O4 .
1. Date of Pumping Date -__-- 2. Quantity Pumped: - ..... _
allons
M
3. Component: i _� Cesspools) V'j' Septic Tank Tight Tank 'i � Grease Trap
Other(describe): _. __ .......
4. Effluent Tee Filter present? Yes IV/, No If yes, was it cleaned? j Yes No
5. Observed condition of component pumped:
_ .... . �� ' � Ur _ . -- °ooc(� k._...........rya A)LeA ..
6. System Pumped By:
Name. � :. .
Vehicle License Number
Stewart's Septic 53 So_Kimball St. , Bradford,MA
Company _.. _.
7. Location where contents were disposed:
20 So.MIIi Bradford,MA
_.._.... -__ -.__.----
- ,. -- ---- ---
u :. Date
t+�fe
Signature of Receiving Facility(or attach facility receipt) Date
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