HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 280 JOHNSON STREET 8/6/2019 Commonwealth of Massachusetts
N W City/Town of- No. Andover
System Pumping Record AUG 0 6 ?����
a TOWN OF NORTH ANDOVER
Form 4 HEALTH DE'ARTMIENT
4„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, T /
use only the tab i ZSa �l 6✓14�S�JI�I ��
key to move your Address
cursor-do not No. Andover MA
key the return City/Town I State Zip Code
Y
2. System Owner:
av(�
Name
mnen
Address(if different from location)
City/Town State Zip Code
Telephone Number
B: Pumping Record _ - - --
1. Date of Pumping ( / 2. Quantity Pumped: / �—
Date Gallons
3. Component: ❑ Cesspool(s) LYJ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes E/No If yes;was it cleaned? ❑ Yes �o
5. Observed condition of component pumped:
6. Sys 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 radf , MA
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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