HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 247 BRIDGES LANE 7/9/2026 1OWn or Nmh Andove,
G Commonwealth of Massachusetts
^ AUG _ 4 2ozs
City/Town of Io.Andover
System Pumping Record
Form 4 i'calth Cie
partment
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 fiom the pumping date in
accordance with 310 CIVIR 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 e1v
cursor-do not
use the return
key. City/Town State Zip Code
2. System Owner:
Q
_.. .w" '
Name -- ---
rsnan
Address(if different-iom location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
_ _
Gallons
3. Component: Cesspool(s) Septic Tank Tight Tank Grease Trap
Other (describe): _
4. Effluent Tee Filter present? Yes YNo If yes, was it cleaned? Yes No
5. Observed condition of component pumped: °
..
........._..__ ------__
6. 5 umped By:
Name Vehicle Licens-e Number
Stewart s Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
.....
774� .. "fie:
g
Si nature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Gate
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