HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 785 TURNPIKE STREET 7/13/2026 ,own of North Andover
Commonwealth of Massachusetts
AUG °- 4 2C1Z6
City/Town of No.Andover
System Pumping Record
W Form 4 Health 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
tilling 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
Q2. System Owner:
Name
(EQN11
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping DaV '? ___ ' Quantity Pumped:
3. Component: Cesspool(s) .i eptic Tank 'Tight Tank _I Grease Trap
Other(describe): ----- - ---
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes No
5. Observed condition of component Y ped:
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic 58 So Kimball St , Bradford,MA
Company
7. Location where con is w disposed:
2 So.Mill Bra ford,MA
w
Signa of Hauler Date
_.... _.. - __ _ _-
Signature of Receiving Facility(or attach facility receipt) Date
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