HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 90 LACY STREET 7/30/2026 Commonwealth of Massachusetts an oforfh Andover
City/Town of _ 1o.Andover AUG -4 2026
.° System Pumping Record
Form 4 HealthDepartment
DEP has provided this 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. Bef,'xe using this form, check with your
local Board of Health ':o determine the form they use. The System Purnping Record must be submitted to
the local Board of Health or other approving authority within 14 days f«om the pumping date in
accordance with 310 (':.'MR 15.351.
A. Facility Information
Important:When
filling out farms 1. System Location:
O computer,
use only he tab
key to move your Address
cursor-do not
use the return -- ------ __._
key. City/Town State Zip Code
2. System Owner:
Name
fERN7!
Address(if different fi�m location)
No.Andover MA
City/Town State Zip Code
Tk.lep;�on�>fJuro7ber
.. ..,_..._.....
B. Pumping Record
�
1. Date of Pumping Date 1_�gl?"_2
2 Quantity Pumped: Gallon
3. Component: Cesspool(s) "'Septic Tank l Tight Tank '_�', Grease Trap
Other(describe):
4. Effluent Tee Filter present? ] Yes 7 No If yes, was it cleaned? Yes .1 No
5. Observed condition of component pumped
Se
6. �ystet Pumped By:
Name Verilde License.Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
Vj
Signature o Hauler Date
signature of Receiving Facility(or attach facility receipt) Date
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