HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 114 REA STREET 8/14/2026 Torn of North Andover
_ Commonwealth of Massachusetts
City/Town ofNa.Andaver rP
w° System Pumping Record
Form 4
Health 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 15.351.
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 :Mate Zip Code
ran 2. System Owner:
_
__.
Name
rertnn
Address(if different frorn location)
No.Andover MA
--- . .._._..
City/Town State Zip Code
Telephone Nwrjoer
B. Pumping Record
1. Date of Pumping 2. QuantityPumped:DateGallons
3. Component: ] Cesspool(s) ; Septic Tank j Tight Tank I Grease Trap
1 Other (describe): -
4. Effluent Tee Filter present? J Yes o If yes, was it cleaned? Yes , ] No
5. Observed condition of component pumped:
' t'` � 5l
6. System F
ped 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
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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