HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 88 DUNCAN DRIVE 6/18/2026 Commonwealth of Massachusetts Town of o*AndoVer
r ka City/Town of North Andover
A System Pumping Record JUL. -, 20
y p g d 7 26
Form 4
Hea '' ''I
DEP has provided this form for use by local Boards of Health. Other forms may �,
information must be substantially the same ;s that provided here. Before using this form, check w t 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, -- µ� ��
use only the tab _..._..
key to move your Address
cursor-do not a .
use the return
key.
City/Town State Zip Code4:1
2. System Owner:
Name
L-A,
-
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. QuantityPumped: `� 0
Dat Gallons
3. Component: Cesspool(s) Septic Tank ( Tight Tank _� Grease Trap
Other(describe): _
4. Effluent Tee Filter present? ] Yes i No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
Zvi/ 5� � i tlb .�r
6. System—Pumped By:
Ji v
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
_ --.
Company
7. Location where contents were disposed:
0 So.Mill r ord,M
i
_..to_reo_f....: ._ er Date
jS e
Signature of Receiving Facility(or attach facility receipt) Date
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