HomeMy WebLinkAbout- - Septic Pumping Slip - 871 FOREST STREET 8/4/2026 (3) [ Commonwealth of Massachusetts Town of North Andover
City/Town of No.Andover 5EP 3 2026
a a
System Pumping Record
Form 4
M Health Department
DEP has provided thic,,�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 out forms 1. System Location:
on the computer,
use only the tab f `p
.........._ _------
key to move your Address ----- -----
___
cursor-do not
use the return ------ _ ---- --
key. City/Town State Zip Code
2. System Owner:
tab
Name
etvm
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record �
1. Date of Pumping Date 2. QuantityPumped: -------.___-
Date p Gallons
3. Component: i Cesspool(s) eptic Tank ] Tight Tank ] Grease Trap
Other(describe):
„g
4. Effluent Tee Filter present? _] Yes o If yes, was it cleaned? ] Yes No
5. Observed condition of component pumped:
a
------ _....- _ .. . -------- -
& System Pumped By:
— _- _._._-.-.._
Name Vehicle License Nurnber
Stew
art's Septic 53 So Kimball St Bradford,MA
---_.-_ ----
Company - -----.
Company
7. Location where contents were disposed:
20 So.Mlll St.,Bradford,MA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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