HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 136 SAW MILL ROAD 8/18/2026 Commonwealth of Massachusetts Town of North Andover
City/Town of No.Andover SEP3 Zozs
System Pumping Record
-f Form 4 Heald". 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,tocal Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 GMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, d ,�
use only the tab -- ------ - l —[/ _........ _.__ tom
key to move your Address _____---_-_--
cursor-do not
use the return -----.. .........._--------- _
key. City/Town State Zip Code
r�
2. System Owner:
r�.
Name.._.... -----
return
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
a
1. Date of Pumping Dat s ` 2....Quantity Pumped: Gallons -
3. Component: Cesspool(s) Septic Tank E Tight Tank ..� Grease Trap
Other (describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes No
5. Observed condition of c4nponent pumped:
6. P
System e Name vehicle License Number
Stewart'§ Se-tic 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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