HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1030 JOHNSON STREET 7/1/2026 Commonwealth of Massachusetts Town of North Andover
City/Town of North Andover
System Pumping Record AUG - 2026
Form 4
DEP has provided this form for use by local Boards of Health. Other fare " rtment
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:
computer,on the
use only thetab
,a
key to move your Address
cursor-do not
use the return _-_--_ ___.. ......
key. City/Town State Zip Code
2. System Owner:
1
Name
endn
Address(if different from location)
City/Town State Zip Code
Telephone Nuriber
B. Pumping Record
1. Date of Pumping - 2. Quantity Pumped-
p g Date y p Gaiians
3. Component: Cesspool(s) I eptic Tank Tight Tank 1 Grease Trap
Other (describe): - _. ....... . ................. -
4. Effluent Tee Filter present? Yes &NO If yes, was it cleaned? Yes _j� No
5. Observed condition of component pumped:
6, System Pumped By:
Name vehicle License=Number--
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So ' .A.....-......,Bradford,M
Signs re Hauler �'' Date
Signature of Receiving Facility(or attach facility receipt) Date
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