HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 122 OLYMPIC LANE 6/19/2026 V, 1 vullO Andover
Commonwealth of Massachusetts JUL ,
2026
City/Town of No.Andover
W System Pumping Record HOalth Depar rn e
Form) 4
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 Infermation
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
t�
2. System Owner.
Name
rerom
Address(if different from location)
No.Andover MA
City/Town State Zip Cade
Telephone Number
B. Pumping Record
_
1. Date of Pumping Date 2. Quantity Pumped; �pns
3. Component.- Cesspool(s) Septic Tank fight Tank ] Grease Trap
Other(describe): ._.... ................................
4. Effluent Tee Filter present? ; YesKNo If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
5. System Pumped By:
Name Vehicle License Number
Stewart's Septic 58 So Kimball St Bradford,MA
Company
7. Location where contents risposed
20 So.Mlll Bradford, A ,
_ - - - - ..
-
Sig ure o auler Date
Signature of Receiving Facility(or attach facility, receipt) Date
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