HomeMy WebLinkAbout- Septic Pumping Slip - 39 DEER MEADOW ROAD 8/6/2019 � Commonwealth of Massachusetts
City/Town of No. Andover
E� VE1
System Pumping Record AUG 0 ?0'N
Form 4
TOWN OF NORTH ANUOVER
DEP has provided this form for use by local Boards of Health. Other forHEALTH� e usiedNl6ut the
Y
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.
I
A. Facility Information
Important:When
1. System Location:
filling out forms y
on the computer,
use only the tab
key to move your Address
cursor-do not No. Andover MA 01845
use the return key. Cityrrown State Zip Code
2. System Owner:
Name
reaun
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dater ( Z r 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System;Pumped By:
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 So. Mill St., Bradford, MA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record.-Page 1 of 1