HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 105 SULLIVAN STREET 7/2/2026 Tt. .p i i ofNorth Andover
Commonwealth of Massachusetts
City/Town of No.Andover AUG - 4 2026
ry System Pumping Record
_ Form 4
K alth 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 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:
Name
renm
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
w� m.
1. Date of Pumping Date _ __ 2, Quantity
Pu1m ped: Gallo
Ti ht Tank Grease TrapSe tic Tank3. Component:
----
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 P mped By'
Name Vehicle License Number
Stewar Septic 58 So Kimball St , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
signature of Mauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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