HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 234 BRIDGES LANE 7/8/2026 t � Commonwealth of Massachusetts iown of Nofth Andover
City/Town of No.Andover AUG 4 2026
System Pumping Record
Form 4
I
lth 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 C:MR 15.351.
A. Facility Information
Important:When
filling tout forms 1. System Location
an ye computer,
use only the tab
o
key to move your Address
cursor-do not
use the return - ---- -
key.
City/Town State Zip Cade
2. System Owner:
C96
". L
Name _.
etwn
Address(if different from location)
No Andover MA
_ _ ..._ _ ---_.__._ _.__ -.__
City/Tawn State Zip Code
Telephone Number
B. Pumping Record
t
1. Date of Pumping �2, QuantityPumped: -�� -
DateGallo
ns
3. Component: Cesspool(s) Septic Tank Tight Tank Grease Trap
Other (describe):
4. Effluent Tee Filter present? , Yes No If yes, was it cleaned? j Yes No
5. Observed conditi of coponent pumped:
C
6, System Pu d By. °
70-1 - - --- - --- -
Nm ae Vehicle License Number
Stewart's Septic 58 So Kimball St Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
Signature of Fla uler _ pate
Signature of Receiving f-aclety(or attach facility receipt) Date
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