HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 46 STANTON WAY 5/29/2026 Town
Commonwealth of Massachusetts f NOnth Andover
M == = City/Town of 1o.Andover � 202
System Pumping Record
Form 4 �f y �y]py
�M A ^wiP u�R. ,.pr�MilYwe • 48 i�yo
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DEP has provided this farm for use by local Boards of Health. Other farms may be used, but the
information must be substantially the same as that provided here. Before using this farm, check with your
local Board of Health to determine the farm 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,
use only the tab
key to move your Address .---....-.---
cursor-do not
use the return —.--__
key. City/Town State Zip Code
2. System Owner:
rsh
Name .......
rennnn
Address(if different from location)
No.Andover MA
City/Town State _._. Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Da .__ 2. Quantity Pumped:
Glans
3. Component: Cesspool(s) Xj Septic Tank i' Tight Tank Grease Trap
Other(describe): ---
4. Effluent Tee Filter present? f Yes li�, No If yes, was it cleaned? Yes _ No
5. Observed condition of component pumped:
C6
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.Mill St.,Bradford,MA
off'- --------. _ ... / /2-
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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