HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 115 CANDLESTICK ROAD 8/7/2026 Commonwealth of Massachusetts Town Of North Andover
g City/Town of No.Andoyer
i
System Pumping Record SEP 3 2026
„ yy Form 4
DEP has provided this form for use by local Boards of Health. O 601 he
information must be substantially the same as that provided here. Before using his form, cl�k 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 DMR 15.351.
A. Facility Information
Important:when
filling out forms 1. S stem Location: lei
on the computer, e d
use only the tab y __. �' � ___ ...
key to move your Address
cursor-do not
use the return key. City/Town State Zip Cade
2. System Owner:
rob
Name
reran
Address(if different from location)
No.Andover MA
City(Tawn State Zip Code
7eleptrone Nurr7ber
B. Pumping Record
1. Date of Pumping ....... 2. QuantityPu ed: _
Date m p Gall ns
3. Component: j Cesspool(s) Y, Septic Tank Tight Tank _ Grease Trap
l Other(describe):
4. Effluent Tee Filter present? Yes o If yes, was it cleaned? Yes _!i No
5. Observed condit
ion of component pumped:
. ,,,_
6.
y „,,
st Pu . ed B
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) D 11 ate
t5form4.docc 11/12 System Pumping Record-Page 1 of 1