HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 149 SUMMER STREET 8/13/2026 Commonwealth of Massachusetts Tarn of North Andover
µ City/Town of No.Andoyer
w° System Pumping Record ZCl2
a = v p
Form 4
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DEP has provided this form for use by local Boards of Health. Other forms mW%AQQa11M0nt
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
VQ 2. System Owner:
Name
reran
Address(if different from location)
No Andover MA
_. -- ... —
City/Town State Zip Code
Telephone Nur4er
B. Pumping Record
rt// -. _1. Date of Pumping "__...._ 2 Quantity Pumped: Ga uan s
3. Component: Cesspool(s) l'v Septic Tank j Tight Tank j _J Grease Trap
Other(describe): ---- ....
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
. 1 ... ..... . -_-
6. System Pump d By ,
Name Vehicle License Number
Stewart's Septic 58 So Kimball St Bradford,MA
Company
7. Location where contents were disposed:
20W
ord,MA
- -
Date
Signature of Receiving Facility(or attach facility receipt) Date
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