HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 107 ROCKY BROOK ROAD 8/7/2026 Commonwealth of Massachusetts Town Of North Andover
City/Town of Jo.Andouer
-- System Pumping Record SEP 3 202
Form 4
DEP has provided thi,,; form for use by local Boards of Health. Othdq*WnQ@P&iMTWPAe
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 farms 1. System Location
on the computer, �s
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._.
remm
Address(if different f-r-orn location)
No.Andover MA
City/Town State Zip Code
Telephone N1.10iher
B. Pumping Record
1. Date of Pumping 6a eV2 ( 2. C2uantity Pumped:
Gallons
3. Component: Cesspool(s) Septic Tank Tight Tank ] Grease Trap
Other(describe):
4. Effluent Tee Filter present? ] YesX,, No If yes, was it cleaned? ] Yes No
5. Observed condition of component pumped:
6. Sit 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
Zile-
Signature of Hauler bate
Signature of Receiving facility(rr attach facility receipt) Bate
t5form4.doc• 11/12 system Pumping Record•Page 1 of 1