HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1881 GREAT POND ROAD 8/12/2026 _ Commonwealth of Massachusetts nwn �� al Andover
- =w City/Town of No.Andover
w System Pumping Record
.,: Form 4P 2026
DEP has provided this form for use by local Boards of Health. Other f sed, but the
information must be substantially the same as that provided here. BeNMI Qp 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
C
filling out forms SystemLocation:on thethe computer, _ _ �P P � 7. i�
use only the tab .....
key to move your Address _
cursor-do not
use the return
key. City/Town State Zip Code
tab
2. System Owner:
Y
Name
ret�an
_._
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Nurnber
B. Pumping Record
1. Date of Pumping Da 2. Quantity Pumped: Gallons
_ .
3. Component: ] Cesspool(s) 'XI
Septic Tank Tight Tank Grease Trap
Other(describe): - - —
4. Effluent Tee Filter present? Yes ] No If yes, was it cleaned? Yes ] No
5. Observed condition of component pumped: .
6. Sy roped By:
Name ...... Vehicle License Number
Stewart's Septic 56 So Kimball St Bradford,MA
Company _
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
_ _-- -- - _
-
Signature of Hauler•-•m Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1