HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 290 BARKER STREET 7/2/2026 T -Nn of No t i Andover
t Commonwealth of Massachusetts
� City/Town of North Andover AUG -4 2026
System Pumping Record
\, Form 4 Flealth Department
~tiM 4l J
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: 1 p
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return — —
key. City/Town State Zip Code
r�
2. System Owner:
-
Name
Bf
Address(if different from location)
- -- .- _.... ........ _._.
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date "p Gall
2. Quantity Pumped: on s ... _-_.
3. Component: Cesspool(s) Septic Tank Tight Tank Grease Trap
J Other (describe):
4. Effluent Tee Filter present? ] Yes No If yes, was it cleaned? Yes No
5. Observed condition of component pumped
6. System Pumped By: /2.
- ---- _--
Name Vehicle License Number
Stewart s Septic 58 So Kimball St Bradford,MA
Company
7. Location where oonten wer disposed:
20 So ill St Bradfo
gn re of auler Date
___._ __ -_.-._. ......._....
Signature of Receiving Facility or attach facility receipt) Date
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