HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 410 SUMMER STREET 6/4/2026 m° n Of tfth Andover
Commonwealth of Massachusetts
City/Town of No.Andover JUL -1 2026
w° System Pumping Record
a � Y p �
Form 4 Hecalth Departmetit
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 CMR 15.351.
A. Facility Infclrmation
Important:When
filling out forms 1. System Location.
on the computer, C "
use only the tab
key to move your Address cursor--do not
usethe return ---- ------ _ ----- _........... _. _._ _.... ....._._----------
key. City/Town State Zip Code
2. System Owner: „
_...
Name
(8f!/JJ7
Address(if different from location)
No.Andover MA
CitylTawn State Zip Code
Telephone NurEiber
mm_
B. Pumping Record _
11. Date of Pumping � - - -- 2. Quantity Pumped: ........
Date y p ----
Ga Ions
3. Component: Cesspool(s) S ptic Tank Tight Tank �i Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes _� No If yes, was it cleaned? es _J No
5. Observed condition of component pumped
6. System Pumped By
"T
� °
Name Vehicle License Number
Stewart's Septic 58 So Kimball St Bradford,MA
Company
7. Location where contents were disposed.
20 So.Mill St.,Bradford,MA
...
of a er Date
Signature of Receiving Facility(or attach facility receipt) Date
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