HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 975 FOREST STREET 7/16/2026 Commonwealth of Massachusetts Town q North Andover
g City/Town of No.Andover
System Pumping Record
f Form 4 AUG ~4 2026
DEP has provided this form for use by local Boards of Health. Other f Irr�i µ ed, but the
information must be substantially the same as that provided here. Bef)r k e s our
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, 6
use only the tab —__
'
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
r�
2. System Owner:
Name ----— — ------------- ---------
ienun
Address(if different from location)
No.Andover MA
CitylTown State Zip Code
Telephone N..^mber
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date ' ----- ---- _..
Gallons
3. Component: Cesspool(s) XSe tic Tank Tight Tank I Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes NO If yes, was it cleaned? j Yes No
5. Observed condition of c mponent umped:
.......
6. System Pum ed
--- -- - -- -- - - _ _ ..... ........... ......._.
Name Vehicle License Number
Stewart's Septic 58 So Kimball St Bradford,MA
Company
7. Location where con ere disposed:
So ill t.,Br ford
7
Sign re of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1