HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 221 FARNUM STREET 6/2/2026 Commonwealth of Massachusetts Town farth Andover
; City/Town of No.Andover JUL -. 2026
System Pumping Record
Form 4 Health Department
DEP has provided th's 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 HeAth 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 --------- -_ - 2� - T ..__ - --- ------ — - -
key to move your Address
cursor-do not
use the return ____._.____._.____...______.._.._._._ ___.
key.
City/Town State Zip Cade
2. System Owner:
tab
Name — --- --- -
IPRAA
Address(if different f-om location)
No.Andover MA
City/Tawn State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - - 2. QuantityPu ed: -���,� ......__
Dat m p Gns _
3. Component: Cesspool(s) Septic Tank Tight Tank .1 Grease Trap
F 1, Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes _� No
5. Observed condition of component pumped:
6. System Pumped By
Vehicle License Number
Stewart's Sep _--.
tic 58 So Kimball St Bradford,MA
m Copany
7. Location where contents were disposed:
20 So.Mi St.,Bradf rd,
bj�_.. ....... .. - - ----- -----
Sig ture of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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