HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 66 BOXFORD STREET 7/20/2026 Commonwealth of Massachusetts Town of N®�h Andover
City/Town of No.Andover AUG 4.2026
<s System Pumping Record
Form 4Health Departt
DEP has provided th s form for use by local Boards of Health. Other farms may be used 3u Mt
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 CMR 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:
,Q � - —
Name
rznrn
Address(if different from location)
No.Andover MA
City/Town State zip-Code-
Telephone Number
B. Pumping Record
1. Date of Pumping tie f 2. Quantity Pumped: Gallon
3. Component: I Cesspool(s) _t Septic Tank L Tight Tank s 1 Grease Trap
Other(describe): _ .......... _ _.
4. Effluent Tee Filter present? li _ Yes , o If yes, was it cleaned? Yes } No
5. Observed condition of mponent pumped:
6. System Pd By
- P-3- -r __ - --- . - - - ---
Name Vehicle License Number
Stewart s Septic 58 So Kimball St , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mlll St.,Bradford,MA
-- - --- -
Signature of H -Date--- - ------..-
auler
Signature of Receiving Facility(or attach facility receipt.) Date
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