HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 280 GRAY STREET 6/15/2026 Nortll Andover
Commonwealth of Massachusetts
City/Town of No.Andover JUL " 7 2026
w5 System Pumping Record
Y p !�
Form 4 Health Department
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 ,;MR 15.351.
A. Facility information _
Important:When
filling out forms 1. System Location:
on the computer, _use only the tab ...._...'�` Yl. J
key to move your Address 7 _........ . .. ......._
cursor-do not
use the return - - -......_ - __..._..
key.
City/Town State Zip Code
Q2. System Owner:
_ ----.._. __ __..... .. .._-_._
Name _._ _.
renun
Address(if different from location)
No.Andover MA
City/Town State Zip Code Telephone Number
B. Pumping Record
1. Date of Pumping ba ere__ c ��_12. (quantity Pumped: Gallons
3. Component: Cesspool(s) Septic Tank i Tight Tank Grease Trap
Other (describe):
4. Effluent Tee Filter present? ] Yes [ _ No If yes, was it cleaned? Yes ] No
5. Observed c ndition component pumped:
6. System ZPmpe d By:
Name Vehicle License Number
Stewart s Sel tic 58 So Kimball St Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doca 11/12 System Pumping Record•Page 1 of 1