HomeMy WebLinkAbout- - Septic Pumping Slip - 231 FOREST STREET 8/6/2026 Town of North Andover
Commonwealth of Massachusetts
M ( City/Town of No.Andover SEP 3 2026
System Pumping Record
Form 4 Heailth 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 15.31.
A. Facility Information
Important:When
filling out forms 1. System Location:
an the computer, -
use only the tab
-key to move your Address -- ---
cursor-do not
use the return _
key. City/Town State Zip Cade
2. System Owner:
Name - --
retwn
Address(if different from location)
No.Andover MA
City/Town State Zip Cade
Telephone Number
B. Pumping Record
1. Date of Pumping Gate 2. Quantity Pumped:
Gallons
3. Component: ] Cesspools) Septic Tank Tight Tank �_J Grease Trap
Other(describe):
4. Effluent Tee Filter present? j Yes No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
---- --
6. System roped By:
Name Vehicle License Number
StewarSepticc 56 So Kimball St , Bradford,MA
Campy
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
Signature of Hauler Gate
Signature of Receiving Facility(or attach facility receipt) Gate
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