HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 506 BOSTON STREET 7/10/2026 mm f or�1`1 Andover
G Commonwealth of Massachusetts
City/Town of No.Andover AUG
-4 2026
System Pumping Record
- 1 Form 4 I-;-,7�:,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 CIVIR 15.351.
A. Facility Information --��
Important:When
filling out forms 1. System Location:
on the computer, e '
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
re2vn
Address(if different frarn location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
00
1. Date of Pumping . Quantity Pumped:
Date P Gallons
3. Component: Cesspool(s) �� Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? . es No If yes, was it cleaned? Yes No
5. Observed condition of co anent pumped.
6. Syste Pu d By: µ.,me
Name Vehicle License Number
Stewart's Septic 56 So Kimball St Bradford.MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
Signature of Hauler Date
Signature of-Receiving Facility Or attach facility receipt) Date
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