HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 11 BRADFORD STREET 8/6/2019 Commonwealth of Massachusetts � d
W City/Town of No. Andover {
W° System Pumping Record AUG 6 ^��
Form 4
TO<NN OF NORTH ANDOVER
M HEALTH DEPARTMENT
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 s
filling out forms 1. System Location:
on the computer, Y LL� �r�
use only the tab i.J
key to move your Address
cursor-do not No. Andover MA
use the return Cityrrown State Zip Code
key.
2. System Owner:
VQ
Name
ieaxn
Address(if different from location)
City/Town State Zip Code
Telephone Number
_ -
1. Date of Pumping —��r l 1 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes E3 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped t'�yl
By:
'Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
20 S . ' S ., Br f ,
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1