HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 931 TURNPIKE STREET 6/3/2026 Commonweaith of Massachusetts lown of NMh Andover
City/Town of No.Andover U 2026
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= System Pumping Record
..
Form 4 �
artment
DEP has provided thi form for use by local Boards of Health. Other forms may be used, buthe
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 CIVIR 15.351.
A. Facility information
Important:When
filling out forms 1. System Location: _
on the computer, 7 KK"
useonly the tabJ / ......................................................---------------
key to move your Address __.
cursor-do not
use the return _ __
key. City/Town State Zip Code
2. System Owner:
Deb f
Name _
Address(if different from location)
No.Andover MA
City/Town State Zip Code
Telephono Number
B. Pumping Record
1. Date of Pumping Da e �' - ---- 2. Quantity Pumped:
G ons
3. Component: Cesspool(s) j Septic Tank ] Tight Tank Grease Trap
11 Other(describe): ... ............
4. Effluent Tee Filter present? Yetmped:
If yes, was it cleaned? Yes No
5. Observed condition of component
7-6
6. :ysl Pu e
dme Vehicle` _..�...
License Number
Stewart"s Se tic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 s ,
a
Signature o er Date
Signature of Receivinrj Facility(or attach facility receipt) Date
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