HomeMy WebLinkAbout- - Septic Pumping Slip - 39 SPRING HILL ROAD 8/4/2026 TOW/7 Of
Commonwealth of Massachusetts Andover
1 City/Town of No.AndoverP
a
System Pumping Record
ozs
Form 4 t
DEP has provided this form for use by local Boards of Health. Other forms may be used, buu tll7 ety
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 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
2. System Owner:
rab r
Name
!Etld71
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Gallons
(j �- -- 2. Quantity Pumped:
Date
3. Component: Cesspool(s) eptic Tank Tight Tank _ Grease Trap
Other(describe):
4. Effluent Tee Filter present? .] Yes 1KNIo If yes, was it cleaned? Yes [ _� No
5. Observed condition of component pumped:
6. System Pumped By:
— --- - - --- - - - --.. - -------
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
-- --- - -.... . ......_ _..--- _ - -- ---------
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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