HomeMy WebLinkAboutSludge Tank - Septic Pumping Slip - 351 WILLOW STREET 8/6/2019 Commonwealth of Massachusetts C���craLV E ,
City/Town of No. Andover ?019
System Pumping Record
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Form 4 TGy,q�,i OI NORTH ANDOVER
E,EALTH Dr- I MENT
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 only
the tab
UVI I/O
use only the tab _ / r
key to move your Address
cursor-do not No. Andover MA
use the return
key. City/Town State Zip Code
2. System Owner: I
Name
tenon
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping'Reco'rdj
1. Date of Pumping Date ' 2. Quantity Pumped:
Gallons
i
3. Component: ❑ Cesspool(s), ❑ Septic Tan lf j❑ Tight Tank ❑ Grease Trap
Other(describe): l ~
4. Effluent Tee Filter present? ❑ Yes VO If yes, was it cleaned? ❑ Yes ❑ No
5. Observed co dition of component pumped:
6. System P d By:
e
Name Vehicle License Number
Stewart's Septic 58 So. Kimball,St., Bradford MA
Company
7. Location where contents were disposed:
20 Sp. Mill St. Bradford, MA
I
iSign ure of Ha r Date
Signature of Receiving Facility(or attach facility receipt) Date
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