HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 19 OLYMPIC LANE 7/10/2026 r Commonwealth of Massachusetts �� ofklo�i', Andover
g(� City/Town of Forth Andover
System Pumping Record AUG 2026
Form 4
DEP has provided this form for use by local Boards of Health. Other 4'II`n
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 Locatiom
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:
rab e'� 1 .
Name _. _ _ _... _._.-... __._....
renrn
Address(if different from location)
City/Town Stat 11 e Zip Code
Telephone Number
_ ........
B. Pumping Record 1. Date of Pumping i e __ �. _ 2. Quantity Pumped: __ -/ ,"�pp�
t /.__.-
Gal ons
3. Component: Cesspool(s) Septic Tank "right Tank Grease Trap
Other(describe): __
4. Effluent Tee Filter present? ] Yes �- No If yes, was it cleaned? Yes ] No
5. Observed condition of component pumped:
& System P roped By:
- - _.. . . L . ... _......
Name 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 /
r of ..:.solar Date
Signature of Receiving Facility(or attach facility receipt) Date
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