HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 515 BOSTON STREET 6/4/2026 ,own of, 01)Andover
Commonwealth of Massachusetts JUL
M City/Town of No.Andover
System Pumping Record11 , e
Form 4a� n
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 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:
retr
Name
reran
Address(if different frr,m location)
No.Andover MA
City/Town State Zip Code
--_ --- -- -- -- —
�reiephone--- Nur�rber
B. Pumping
p' g
oat - ;---- Pumped: ...�,,..� �....
1. Date of Pumping __ - - 2. Quantity Gallons
3. Component: ] Cesspool(s) [ Septic Tank ] Tight Tank ] Grease Trap
Other(describe): ------ ---__.. ....................... - -----
4. Effluent Tee Filter present? ] Yes /No If yes, was it cleaned? _� Yes ] No
5. Observed condition of component pumped
cra
5. System Pumped By
< I 4
Name'- -
Vehicle License Number
Stewar s Septic 58 So Kimball St. , Bradford,MA
------ - -. .-................____-----------
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
' le, `
S pi 10 uler Date
Signature of Receiving Facility(or attach facility receipt) Date
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