HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 135 JOHNNY CAKE STREET 8/6/2019 �LN Commonwealth of Massachusetts RECOE®
City/Town of No. Andover AUG 0 6 201l
a System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
�M
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. 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, �W J 0/q ]�
� use only the tab v�.Yq lI
key to move your Address
cursor-do not No. Andover
use the return Cit /Town MA
key. y State Zip Code
VQ 2. System Owner:
6M
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number _
Record �.
1. Date of Pumping Date, ( 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) P Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed cond' ion of component pumped:
9'r'Gar.J
6. System Pumped f—
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford MA
Company
7. Location where contents were disposed:
20 S97 Mill St.,jfadford,
7' a " 1,9
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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