HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 246 BRADFORD STREET 8/20/2026 Commonwealth of Massachusetts Town of North Andover
x City/Town of No.Andover
System Pumping Record SEP 3 2026
r Form 4
Neap De�y ��g erg
DEP has provided this:;,form for use by local Boards of Health. Other forms may e usecf;' u`t"tYie
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 HeP.Ith or other approving authority within 14 days from the pumping date in
accordance with 310 (,,MR 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
2. System Owner: -.
Name _- - -- --- ------
fBh%I7
Address(if different from location)
No.Andover MA
own
State Zip-i-p� C__-__-
ode_-- ____
City/T -_.
Telephone Nornber
B. Pumping Record /0001
1. Date of Pumping ___._..bat uantitY Pumped:
Gallons
3. Component: j Cesspool(s) Septic Tank j Tight Tank 1 Grease Trap
Other(describe): -- ---- --- -
4. Effluent Tee Filter present? Yes ] No If yes, was it cleaned? Yes j No
5. Observed condition f compon nt pumped:
& System Pu pe By:
Name vehicle License,Number
Stewart's Septic 58 So Kimball St , Bradford,MA
_._... -------Compaa ny
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
Signature of Hauler Date
Si nature of Receiving Facility(or attach facility receipt) Date
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